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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003772
Report Date: 09/29/2021
Date Signed: 09/29/2021 09:58:39 AM

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:DIVINE GRACE VILLAFACILITY NUMBER:
306003772
ADMINISTRATOR:EVELYN DE GARRIZFACILITY TYPE:
740
ADDRESS:9662 KATELLA AVENUETELEPHONE:
(714) 533-0841
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 2DATE:
09/29/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Evelyn De GarrizTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced plan of correction visit to follow up on citations issued on 09/10/2021. LPA was greeted and granted entry into the facility by Licensee/ Administrator Evelyn De Garriz and explained the reason for the visit.

At 9:45 AM, LPA toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 87468(c) has been cleared. Department postings are posted prominently in the entrance of the facility. Licensee has complied with the terms of the POC.

Advisory note dated 09/10/2021 advised Licensee to clean the patio room off the garage. LPA observed during today's visit the patio has been cleaned and organized.




No deficiencies noted during today's visit. Exit interview conducted and a copy of this report 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: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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