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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003971
Report Date:
02/02/2023
Date Signed:
02/02/2023 10:50:30 AM
Document Has Been Signed on
02/02/2023 10:50 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:
NANCITA HOME
FACILITY NUMBER:
306003971
ADMINISTRATOR:
AARON RESURRECCION
FACILITY TYPE:
735
ADDRESS:
713 N. NANCITA STREET
TELEPHONE:
(714) 220-2657
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
6
CENSUS:
5
DATE:
02/02/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:10 AM
MET WITH:
Rodolfo Viquiera
Louise Igisaiar
TIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a case management visit and met with Staff Rodolfo Viquiera. During the visit LPA Gutierrez took a guided tour of the inside and outside of the facility with Staff Mary Jane Amurao. Staff Arbie Alba was also present at the facility.
The purpose of the visit was to confirm Staff 1 (S1) is no longer working or residing at the facility due to Exclusion Order. LPA Gutierrez confirmed S1 was not present at the facility and Staff Viquiera confirmed that S1 has not worked or been present at the facility since 1/25/23.
Administrator (AD) Louise Igisaiar arrived at 10:38 a.m. 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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