<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001232
Report Date: 07/28/2021
Date Signed: 07/28/2021 10:31:06 AM

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:MEMORY LANE ELDERLY CAREFACILITY NUMBER:
306001232
ADMINISTRATOR:BORDUZ, FLAVIA & GHEORGHEFACILITY TYPE:
740
ADDRESS:2507 W. KEYS LANETELEPHONE:
(714) 484-6639
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 1DATE:
07/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Administrator Gheorghe Borduz TIME COMPLETED:
10:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management. LPA was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA met with Administrator (AD) Gheorghe Borduz and stated the purpose of this visit.

LPA Marin tour the interior portion of the facility. AD discussed the COVID 19 mitigation plan of the facility; and provided a copy to LPA.

For this visit, no deficiency was observed, no citation was issued at this time.

LPA Marin conducted an exit interview with AD Borduz and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1