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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004532
Report Date:
08/08/2024
Date Signed:
08/08/2024 03:43:50 PM
Document Has Been Signed on
08/08/2024 03:43 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:
ASSISTED SENIOR HOME
FACILITY NUMBER:
306004532
ADMINISTRATOR:
Z. GLOUNER
FACILITY TYPE:
740
ADDRESS:
24741 PRISCILLA
TELEPHONE:
(949) 248-9415
CITY:
DANA POINT
STATE:
CA
ZIP CODE:
92629
CAPACITY:
6
CENSUS:
0
DATE:
08/08/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:15 PM
MET WITH:
Z Glouner
TIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to conduct a closure visit. LPA was greeted and granted entry into the facility and explained the reason for the visit.
Licensee submitted intent to close facility on 07/15/2024. Licensee indicated the last resident moved out on 08/05/2024. LPA toured the facility and observed no residents residing at facility and facility is undergoing renovations. Licensee to mail license to Regional Office.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Kimberly Lyman
TELEPHONE:
(714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2024
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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