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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003953
Report Date: 12/13/2022
Date Signed: 12/13/2022 01:49:08 PM


Document Has Been Signed on 12/13/2022 01:49 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:NOHL RANCH ELDERLY CARE IIIFACILITY NUMBER:
306003953
ADMINISTRATOR:GABE/MARIANA CORCHESFACILITY TYPE:
740
ADDRESS:2128 E. WHITE LANTERN LANETELEPHONE:
(714) 282-8807
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 3DATE:
12/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mariana CorchesTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit. LPA Haley was greeted, granted entry and explained the reason for today visit. LPA Haley met with Licensee/Administrator (AD) Mariana Corches.

The purpose of today's visit was to speak with resident and staff regarding the Unusual Incident Report (LIC 624) that was sent to the Orange County Adult and Senior Care Program Regional Office December 5, 2022 that involved Resident 1 (R1).

During the visit LPA Haley interviewed AD Mariana Corches, Staff 1 (S1), Resident 2 (R2), and Resident 3 (R3). LPA Haley received copies of R1 and R2's Physician's Report, Appraisal Needs and Service Plan, Emergency Contact Information, and Individualized Service Plan.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report and LIC811s was provided to AD Mariana Corches.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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