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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003735
Report Date:
09/28/2022
Date Signed:
09/28/2022 06:22:21 PM
Document Has Been Signed on
09/28/2022 06:22 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:
JAIRE HOME II
FACILITY NUMBER:
306003735
ADMINISTRATOR:
ANA BIEN DEVERA
FACILITY TYPE:
735
ADDRESS:
1242 ALAMO STREET
TELEPHONE:
(714) 635-3788
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
6
CENSUS:
4
DATE:
09/28/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
06:17 PM
MET WITH:
LOUISE IGISAIAR
TIME COMPLETED:
06:25 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to return the staff files (22) and 3 paper files that were removed from facility as part of the investigation into complaint#22-AS-20220916114701
(See LIC 9099 dated 9/22/22). LPA returned all staff files to the facility. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/28/2022
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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