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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002211
Report Date: 05/19/2023
Date Signed: 05/19/2023 03:30:55 PM


Document Has Been Signed on 05/19/2023 03:30 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:PRECIOUS MOMENTS GUEST HOMEFACILITY NUMBER:
306002211
ADMINISTRATOR:DIANE PACAFACILITY TYPE:
740
ADDRESS:1416 BIRCHMONT DR.TELEPHONE:
(714) 999-6644
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 0DATE:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Diane PacaTIME COMPLETED:
03:45 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying facility closure. LPA met with Licensee (LE) Diane Paca and explained the reason for today’s inspection.

LPA was informed that the facility is closing and that the facility had no residents. The last resident left the facility on 09/09/22. LE surrendered the facility’s license to LPA during today’s inspection. The reason for today's inspection is to confirm the closure of the licensed facility.

LPA toured the facility with LE and observed no residents in care. LPA observed the home to be empty and found no evidence the home is operating as a licensed facility. LPA observed that the facility is no longer operating as a licensed facility and is closed. LPA provided the forfeiture letter to LE during the inspection.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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