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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004435
Report Date:
01/20/2023
Date Signed:
01/20/2023 01:48:00 PM
Document Has Been Signed on
01/20/2023 01:48 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:
STONYBROOK RESIDENTAL CARE I
FACILITY NUMBER:
306004435
ADMINISTRATOR:
BRANDON PENALOSA
FACILITY TYPE:
735
ADDRESS:
9542 STONYBROOK DRIVE
TELEPHONE:
(657) 208-1902
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92804
CAPACITY:
5
CENSUS:
5
DATE:
01/20/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Gladys Framo- House Manager
TIME COMPLETED:
02:00 PM
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver amended findings for complaint control 22-AS-20221209161303. LPA was greeted and granted entry into the facility by Gladys Framo
The amended report was reviewed and signed by facility representative.
Exit interview conducted and a copy of this report was provided and left at facility.
SUPERVISORS NAME
:
Alisa Ortiz
LICENSING EVALUATOR NAME
:
Andrea Mendivil
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/20/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/20/2023
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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