<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004660
Report Date:
07/19/2022
Date Signed:
07/12/2023 12:39:36 PM
Document Has Been Signed on
07/12/2023 12:39 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:
MERCEDES DIAZ HOMES INC - ACACIA
FACILITY NUMBER:
306004660
ADMINISTRATOR:
GRISELDA ELAIR
FACILITY TYPE:
735
ADDRESS:
1231 N ACACIA ST
TELEPHONE:
(714) 603-7850
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92805
CAPACITY:
5
CENSUS:
DATE:
07/19/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
TIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Claudia Gutierrez made an attempted visit for the purpose of conducting an unannounced case management visit.
SUPERVISORS NAME
:
Armando J Lucero
LICENSING EVALUATOR NAME
:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/19/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1