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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002673
Report Date: 05/24/2022
Date Signed: 05/31/2022 11:46:04 AM


Document Has Been Signed on 05/31/2022 11:46 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/31/2022 07:47 AM

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

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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to this facility to conduct a case management. LPA meet with Benjamin Mocan, Administrator and explained the purpose of this visit via telephone call. Administrator arrived shortly after and met with LPA.

On March 14, 2022 LPA conducted an annual inspection and was informed that facility had no residents due to possible change of ownership. As of March 01, 2022 the facility had no residents and was closed. LPA was informed that all resident had been moved out and relocated due to the facility planning to close. Last resident moved out and relocated on February 28, 2022. LPA was informed May 17, 2022 that home had been sold and Licensee no longer had control of the property.

For this visit, LPA toured the exterior portion of the facility. From the outside, LPA Martinez did not observe any residents in care. LPA observed observed workers working on the home with a large trash container on site. No sign of care being provided.

LPA Martinez conducted and exit interview with Administrator and provided a copy to Administrator.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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