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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004839
Report Date: 08/21/2024
Date Signed: 08/21/2024 04:19:27 PM


Document Has Been Signed on 08/21/2024 04:19 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:FULLERTON VILLAFACILITY NUMBER:
306004839
ADMINISTRATOR:DARLENE LINDLEYFACILITY TYPE:
740
ADDRESS:2441 W. ORANGETHORPE AVE.TELEPHONE:
(714) 992-5380
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:197CENSUS: 172DATE:
08/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Jae Wan Rim & Darlene LindleyTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA) Lydia Martinez conducted this Case Management evaluation, in conjunction with a complaint visit Control Number 22-AS-20240819160531. The purpose of this visit was to conduct a Health and Safety evaluation.

LPA, along with AD Rim and AD Lindley toured the facility. LPA observed Residents in care appeared to be safe no imminent health and safety hazards were observed. LPA observed residents in their respective rooms and in the activity room playing Bingo others were roaming around the facility. LPA observed residents to be well groomed and no visible injuries noted. Rooms were observed clean and free of foul odor. Food supply was observed to be adequate during this inspection. Facility was maintained at a comfortable temperature for the residents in care.

There were no deficiencies issued during this Case Management visit. LIC9102 Advisory Note was issued. An exit interview was conducted with AD Rim and AD Lindley and a copy of this report was sent to email on file.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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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