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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004761
Report Date: 04/05/2024
Date Signed: 04/05/2024 09:33:03 AM


Document Has Been Signed on 04/05/2024 09:33 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CAMBRIDGE COURTFACILITY NUMBER:
306004761
ADMINISTRATOR:LAUREN CHONFACILITY TYPE:
740
ADDRESS:1621 COMMONWEALTH AVENUE, EASTTELEPHONE:
(714) 992-1750
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:99CENSUS: 73DATE:
04/05/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Purchasing Supervisor-Maria JaimeTIME COMPLETED:
09:43 AM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Plan of Correction (POC) visit in conjunction with complaint control #22-AS-20201008113606 and citation issued on 12/28/23. LPA was greeted and granted entry into the facility by Purchasing Supervisor (PS) Maria Jaime and explained the reason for the visit.

On 01/04/2024, AD failed to correct the following:
Deficiency cited under Title 22 Regulation 87507(f) pertaining to Admission Agreements.

Deficiency cited under Title 22 Regulation 87507(f) pertaining to Admission Agreements has NOT been cleared.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with PS Jaime and a copy of this report along with the LIC809D and Appeal Rights were provided at the time of this visit.


SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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 2


Document Has Been Signed on 04/05/2024 09:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CAMBRIDGE COURT
FACILITY NUMBER: 306004761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2024
Section Cited
CCR
87507(f)

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Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement... This regulation was not met as evidenced by: Based on interviews conducted and file reviews the facility failed to follow their non-smoking policy
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Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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as documented per facility's Admission Agreement. This poses a potential risk to resident’s health and safety while in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2