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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004258
Report Date:
02/24/2025
Date Signed:
02/24/2025 04:47:50 PM
Document Has Been Signed on
02/24/2025 04:47 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
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
UNIQUE CARE 3
FACILITY NUMBER:
306004258
ADMINISTRATOR/
DIRECTOR:
JOSEPH NASSIF
FACILITY TYPE:
735
ADDRESS:
9791 CORNWALL AVENUE
TELEPHONE:
(714) 714-0698
CITY:
WESTMINSTER
STATE:
CA
ZIP CODE:
92683
CAPACITY:
6
CENSUS:
6
DATE:
02/24/2025
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:
Maria Jimenez
TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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LPA Michael Tea arrived at the facility to conduct a collateral visit in regards to a complaint at a different facility. LPA Tea was greeted and granted entry into the facility by Administrator (AD) Maria Jimenez and explained the purpose of the visit.
LPA interviewed a client in question regarding matters of complaints at another facility where the client previously resided at.
LPA reviewed this report with the Administrator and provided a copy.
SUPERVISORS NAME
:
Alisa Ortiz
LICENSING EVALUATOR NAME
:
Michael Tea
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/24/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/24/2025
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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