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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005207
Report Date:
11/22/2022
Date Signed:
11/22/2022 09:23:33 AM
Document Has Been Signed on
11/22/2022 09:23 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
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
HARVEST RETIREMENT
FACILITY NUMBER:
306005207
ADMINISTRATOR:
GINGER PO
FACILITY TYPE:
740
ADDRESS:
9011 KNOTT AVE
TELEPHONE:
(714) 821-4130
CITY:
BUENA PARK
STATE:
CA
ZIP CODE:
90620
CAPACITY:
106
CENSUS:
DATE:
11/22/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:05 AM
MET WITH:
Danielle Lucero- Care Coordinator
TIME COMPLETED:
09:45 AM
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver a case management report.
On 11/15/2022 LPA experienced technical difficulties and was unable to deliver Case Management dated 11/15/2022 for amended findings.
An exit interview was conducted and a copy of this report and Case Management dated 11/15/2022 left at facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
11/22/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/22/2022
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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