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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004218
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:03:38 PM


Document Has Been Signed on 03/14/2022 12:03 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:OC KAIGO HOMESFACILITY NUMBER:
306004218
ADMINISTRATOR:KAZUHIRO KOTANIFACILITY TYPE:
740
ADDRESS:22322 SAVONATELEPHONE:
(408) 393-3337
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 0DATE:
03/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Edna Kotani, AdministratorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced case management visit for the purpose to verify facility closure. LPA arrived at facility was greeted and granted entry at the door by Kazuhiro Kotani, Administrator. LPA met with Edna Kotani, Administrator and explained the nature of the visit.

LPA was informed on February 28, 2022 that facility would be closed officially and no longer operating as a licensed facility as of March 21, 2022 when the licensee returns the possession of the property to the landlord. LPA was informed that the last resident was moved out on February 27, 2022. LPA received the intent of closure letter on March 01, 2022 and the surrendered license on today’s visit. The reason for today’s inspection is to confirm the closure of the license facility.

LPA toured the facility and observed no residents in care. LPA observed the home to be empty and found no evidence the home is operating as a licensed facility. Based on the observations, the facility is no longer operating as a licensed facility and is closed.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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