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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004060
Report Date:
05/06/2022
Date Signed:
05/12/2022 10:57:05 AM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
05/12/2022 10:57 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:
COYOTE HILLS RESIDENTIAL CARE
FACILITY NUMBER:
306004060
ADMINISTRATOR:
MIKE SFERDIAN
FACILITY TYPE:
740
ADDRESS:
8271 COUNTRY CLUB DRIVE
TELEPHONE:
(714) 690-8000
CITY:
BUENA PARK
STATE:
CA
ZIP CODE:
90621
CAPACITY:
6
CENSUS:
DATE:
05/06/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:30 PM
MET WITH:
TIME COMPLETED:
01:15 PM
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SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 703-2857
LICENSING EVALUATOR NAME:
Michelle Reed
TELEPHONE:
(714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE:
05/06/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/06/2022
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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