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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001350
Report Date: 06/01/2022
Date Signed: 06/01/2022 10:28:21 AM


Document Has Been Signed on 06/01/2022 10:28 AM - 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:ANITA'S ELDERLY CARE HOMEFACILITY NUMBER:
306001350
ADMINISTRATOR:PEDROZA, ANA H.FACILITY TYPE:
740
ADDRESS:25362 DIANA CIRCLETELEPHONE:
(949) 457-0155
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
06/01/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Ana PedrozaTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an announced case management visit to this facility. LPA met with Administrator (AD) Ana Pedroza; and stated the purpose of this visit.

On April 21, 2022, Community Care Licensing Division (CCLD) Orange Office received information from AD Pedroza that she is planning to close the facility soon. At that time she only had one resident in care. On May 31, 2022, the resident moved out and transferred to another licensed facility. LPA Marin confirmed the admission in the new facility.

For this visit, LPA Marin toured the interior and exterior portions of the facility with AD Pedroza. LPA did not observed any resident in care. LPA discussed with AD that in the future, if the licensee decides to provide care and supervision services in this location, the licensee needs to apply for a new license before she can provide the services. AD understood. AD surrendered the original copy of the license to LPA. This facility is closed effective June 1, 2022.

LPA Marin conducted an exit interview with AD Pedroza; 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: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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