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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004761
Report Date: 05/22/2023
Date Signed: 05/22/2023 03:17:19 PM


Document Has Been Signed on 05/22/2023 03:17 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:CAMBRIDGE COURTFACILITY NUMBER:
306004761
ADMINISTRATOR:LAUREN CHONFACILITY TYPE:
740
ADDRESS:1621 COMMONWEALTH AVENUE, EASTTELEPHONE:
(714) 992-1750
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:99CENSUS: 70DATE:
05/22/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lauren ChonTIME COMPLETED:
03:30 PM
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This unannounced case management inspection is being conducted by Licensing Program Analysts (LPA) Dwayne Mason Jr. and Sean Haddad for the purpose of following up on Legal Case CDSS No. 7923020001 involving Witness #1 (W1). LPAs met with Administrator (AD) Lauren Chon and discussed the purpose of the inspection.

During today’s inspection, LPAs toured the facility with AD and observed no health and safety issues. LPAs served a copy of the Accusation for Legal Case CDSS No. 7923020001 on AD. LPAs requested and reviewed copies of the Resident Roster and Staff Roster. LPAs reviewed the facility’s Guardian Roster, Facility Personnel Report Summary, and Staff Roster and confirmed W1 is not a staff of the facility. AD stated the facility has no record of W1 ever being a staff at the facility. LPAs interviewed 4 staff who confirmed W1 is not a staff at the facility.


Based on the information obtained during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
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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