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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003385
Report Date: 08/05/2020
Date Signed: 08/05/2020 03:39:36 PM

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:FAMILY CHOICE SENIOR CARE 4FACILITY NUMBER:
306003385
ADMINISTRATOR:VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: DATE:
08/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Anita CsukardiTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Criss Trinidad conducted an unannounced visit to Family Choice Senior Care 4 in conjunction with a complaint investigation visit with control number 22-AS-20200804151931. The purpose of this Case Management visit was to conduct a health and safety evaluation. LPA was allowed entry into the home and met with Administrator Anita Csukardi.

LPA Trinidad along with Administrator Csukardi inspected the inside of facility and no immediate health/safety concerns were observed. Residents appeared to be groomed appropriately and no visible injuries noted. LPA inspected facility food supplies, food supplies were observed to be adequate during this inspection. LPA Trinidad along with Administrator Csukardi inspected outside perimeter of the facility to ensure no health/safety hazards were present and none were observed. Facility was maintained at a comfortable temperature for the residents in care.

There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Administrator Csukardi and a copy of this report along with the LIC 811 was provided at the time of this visit.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss TrinidadTELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
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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