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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003806
Report Date: 06/03/2022
Date Signed: 06/03/2022 11:52:52 AM


Document Has Been Signed on 06/03/2022 11:52 AM - 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:EXTRAORDINARY ASSISTED LIVING OF HUNT. BEACHFACILITY NUMBER:
306003806
ADMINISTRATOR:DONABELLE GABOYAFACILITY TYPE:
740
ADDRESS:6031 SYDNEY DRIVETELEPHONE:
(714) 625-5544
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 0DATE:
06/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Administrator, Donabelle GaboyaTIME COMPLETED:
12:00 PM
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On today’s date June 3, 2022 Licensing Program Analyst (LPA) Jenifer Tirre conducted a Licensee/Administrator initiated visit to the facility to obtain the surrendered license for facility closure, and to ensure there are no residents that require care and supervision residing at the facility. LPA Tirre was granted entry by Licensee/Administrator Donabelle Gaboya.

On today’s date, LPA Tirre toured the facility to confirm there are no residents currently residing in the facility. LPA Tirre explained to Licensee/Administrator Donabelle Gaboya if at any time they provide care to individuals at this home after surrendering license, that they would need to apply for a new license. Licensee/Administrator Donabelle Gaboya stated she understood.

Exit interview was conducted with Licensee/Administrator Donabelle Gaboya and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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