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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002482
Report Date: 12/03/2024
Date Signed: 12/03/2024 03:31:51 PM

Document Has Been Signed on 12/03/2024 03:31 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CAREWELL MANORFACILITY NUMBER:
306002482
ADMINISTRATOR/
DIRECTOR:		CAROL WILSONFACILITY TYPE:
740
ADDRESS:3330 W. STONYBROOK DRIVETELEPHONE:
(714) 827-8520
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Carol Wilson - AdminstratorTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 12/3/2024 LPAs Dwayne Mason Jr and Fred Arias arrived at the facility for the purpose of conducting a case management visit to return files taken from the facility.

On 11/26/2024, LPA Mason conducted a 10-day complaint visit and borrowed the following files from the facility: resident roster, staff roster, infection control plan, disaster plan, training records, personnel records, CPR certification, admission agreements and facility sketch

Administrator received the original files.

LPAs reviewed the report with the Administrator and provided a copy.
Armando J LuceroTELEPHONE: (949) 430-1222
Dwayne L MasonTELEPHONE: () -
DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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