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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306000889
Report Date:
02/08/2024
Date Signed:
02/08/2024 02:48:38 PM
Document Has Been Signed on
02/08/2024 02:48 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CA
FACILITY NUMBER:
306000889
ADMINISTRATOR:
KAT FARRIS
FACILITY TYPE:
741
ADDRESS:
16850 E. BASTANCHURY ROAD
TELEPHONE:
(714) 577-9281
CITY:
YORBA LINDA
STATE:
CA
ZIP CODE:
92886
CAPACITY:
76
CENSUS:
29
DATE:
02/08/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
12:25 PM
MET WITH:
Kat Farris
TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of a Plan of Correction (POC) visit based on deficiencies cited on 12/05/2023. LPA was greeted and granted entry into the facility and explained the reason for the visit.
*Deficiency cited under Title 22 Regulation 87412(c) pertaining to Personnel Records has been cleared. Licensee provided proof of annual training. Licensee has complied with the terms of the POC.
Licensee has been advised to maintain all items in compliance with Title 22 regulations.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Kimberly Lyman
TELEPHONE:
(714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE:
02/08/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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