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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001397
Report Date: 08/30/2021
Date Signed: 08/30/2021 04:13:46 PM

Document Has Been Signed on 08/30/2021 04:13 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:JONATHAN'S HOMEFACILITY NUMBER:
306001397
ADMINISTRATOR:PRISCILLA S. BUSTAMANTEFACILITY TYPE:
735
ADDRESS:1519 SHELTON STTELEPHONE:
(714) 754-7184
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 4DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:House Manager Levi MiraTIME COMPLETED:
04:20 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and was granted entry into the facility by staff. LPA Tirre met with House Manager Levi Mira and explained the reason for the visit.

During the visit LPA toured the facility with House Manager, Facility is a 4 bedroom and 2 bathroom single story home. There are 4 Clients in care. LPA observed proper covid signage at front entrance of facility. Facility has required Department postings. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Clients were observed relaxing in living room. LPA observed Administrator certificate expiring 10/25/22.

Facility has supplies of PPE but not 30 days supply, LPA reminded House Manager of Department guidelines. Facility has ample food supply. Facility has charged fire extinguisher. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. Clients emergency contact information and Physicians orders are current.

An exit interview was conducted with House Manager and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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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