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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003735
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:50:43 PM

Document Has Been Signed on 02/02/2023 01:50 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 IIFACILITY NUMBER:
306003735
ADMINISTRATOR:ANA BIEN DEVERAFACILITY TYPE:
735
ADDRESS:1242 ALAMO STREETTELEPHONE:
(714) 635-3788
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 4DATE:
02/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Louise IgisaiarTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a case management visit. LPA Gutierrez initiated visit by conducting a required annual inspection. During the inspection LPA Gutierrez conducted a tour of the inside and outside of the facility with Staff Rosalina Amante.

The purpose of this case management visit is to confirm Staff 1 (S1) is not present, working, or residing at the facility due to Exclusion Order. During inspection LPA Gutierrez confirmed S1 was not present at the facility. LPA met with Administrator (AD) Louise Igisaiar and a copy of Decision and Order was provided.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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