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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001397
Report Date: 11/10/2021
Date Signed: 11/10/2021 12:20:00 PM

Document Has Been Signed on 11/10/2021 12:20 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: 2DATE:
11/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrators, Priscilla Bustamante and Patricia FestinTIME COMPLETED:
12:30 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre was out conducting a 10 day visit to facility and during visit LPA toured facility and did a follow up to the last Case Management visit regarding property damage at facility. LPA Tirre observed that the previous holes in the walls in the living room areas and in client bedroom have been patched up and painted. The client room has been freshly painted, no more graffiti on walls and no more holes. Bedroom door has been fixed and new hinges have been replaced. Administrator Bustamante states there is still a few more fixes they have to work on like the fan and the window. Facility looks in better condition than previously. No other additional observations of damages were noted during visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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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