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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003412
Report Date:
02/03/2023
Date Signed:
07/12/2023 12:36:47 PM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
07/12/2023 12:36 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:
CENTER CARE HOME
FACILITY NUMBER:
306003412
ADMINISTRATOR:
GILBERT SINGH
FACILITY TYPE:
735
ADDRESS:
17135 SANTA CATHERINE STREET
TELEPHONE:
(714) 588-4141
CITY:
FOUNTAIN VALLEY
STATE:
CA
ZIP CODE:
92708
CAPACITY:
6
CENSUS:
DATE:
02/03/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
TIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an attempted unannounced visit for the purpose of conducting a required annual inspection.
SUPERVISORS NAME
:
Armando J Lucero
LICENSING EVALUATOR NAME
:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/06/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/06/2023
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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