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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003971
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:50:51 PM

Document Has Been Signed on 09/29/2021 02:50 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:NANCITA HOMEFACILITY NUMBER:
306003971
ADMINISTRATOR:AARON RESURRECCIONFACILITY TYPE:
735
ADDRESS:713 N. NANCITA STREETTELEPHONE:
(714) 220-2657
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 4DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Clarisse Marcelino, Ariel ResurreccionTIME COMPLETED:
03:11 PM
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Licensing Program Analyst (LPA)Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA explained the reason for the visit. Administrator Clarisse Marcelino arrived at 1:30 pm. Ariel Resurreccion arrived at 1:37 pm. LPA, Administrator and Ariel Resurreccion toured the facility. Facility has 7 bedrooms. One bedroom is for staff. One bedroom is vacant. All client rooms were clean and organized. All clients were present during today's visit. LPA observed 3 staff members working at the facility. Both bathrooms were clean and operational. LPA inspected the kitchen. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. LPA observed knives and toxins locked under the kitchen sink. LPA observed the kitchen is clean and organized. The attached garage has a seating area with a TV for clients to watch. LPA and Administrator toured the backyard. LPA observed two sheds. No bodies of water observed. Both sheds are kept locked and used to store supplies. Both exit gates are operational. Facility has a mitigation plan that is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted with the Administrator and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
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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