<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003564
Report Date: 11/19/2021
Date Signed: 11/19/2021 12:20:46 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:JUST LIKE HOME IIFACILITY NUMBER:
306003564
ADMINISTRATOR:ROBERT MASSUCOFACILITY TYPE:
740
ADDRESS:10265 SHERWOOD CIRCLETELEPHONE:
(714) 532-4405
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY:6CENSUS: 5DATE:
11/19/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Elmer BesanaTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced plan of correction visit to follow up on citations issued on 10/28/2021. LPA was greeted and granted entry into the facility by Caregiver Elmer Besana and explained the reason for the visit.

At 12:07 PM, LPA toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. All medications have been centrally stored. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. LPA observed all burners on the cook top are operational. Licensee has complied with the terms of the POC.

Advisory note dated 10/28/2021 advised the following:
  • Facility to post regulation size "Let Us No" poster in entrance of facility. Poster is posted in entrance and of the correct size.
  • Please remove mold/ mildew in restroom. Staff indicates facility is working on it. LPA observes mildew is visibly less.


Exit interview conducted and a copy of this report as well as clearance letter was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1