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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002990
Report Date: 12/08/2021
Date Signed: 12/08/2021 10:36:49 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
FACILITY NAME:EXTRAORDINARY ASSISTED LIVING OF ANAHEIMFACILITY NUMBER:
306002990
ADMINISTRATOR:DONABELLE GABOYAFACILITY TYPE:
740
ADDRESS:1809 W. CERRITOS AVENUETELEPHONE:
(714) 625-5544
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 0DATE:
12/08/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Donabelle GaboyaTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an announced visit to follow up on a licensee initiated facility closure. LPA was greeted and granted entry into the facility by Administrator/ Licensee Donabelle Gaboya.

Licensee submitted written intent to LPA to close facility effective January 1, 2022. Licensee provided a written 60 day notice to residents and responsible parties. The last resident moved out on December 1, 2021.

During the visit, LPA toured the facility and observed no residents residing in the facility. Licensee surrendered facility license during the visit.




Exit interview conducted and a copy of this report was left with Licensee.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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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