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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004293
Report Date: 05/08/2023
Date Signed: 05/09/2023 10:35:08 AM

Document Has Been Signed on 05/09/2023 10:35 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:STEVENS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004293
ADMINISTRATOR:ROMMEL MENDOZAFACILITY TYPE:
735
ADDRESS:106 W. STEVENS AVENUETELEPHONE:
(714) 662-5717
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 2DATE:
05/08/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Arjhun GarciaTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this annual/random visit. LPA arrived at the facility was greeted and granted entry to the facility by Junias Hutabarat, Direct Care Staff. LPA spoke to Arjhun Garcia Lead Direct Care Staff and LPA explained the nature of the visit.

The facility has two clients in care. Upon entry LPA observed there was one clients in living room waiting for day program pick up. Due to time constraint LPA will return at a later date to complete annual inspection.

This report was reviewed with facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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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