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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005316
Report Date: 07/03/2024
Date Signed: 07/03/2024 12:46:45 PM


Document Has Been Signed on 07/03/2024 12:46 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:ANAHEIM CROWN PLAZAFACILITY NUMBER:
306005316
ADMINISTRATOR:JOHNSON, CAMMYFACILITY TYPE:
740
ADDRESS:641 SOUTH BEACH BLVDTELEPHONE:
(714) 827-7007
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:200CENSUS: 138DATE:
07/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Jerry PerezTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Jerry Perez the Health Services Director and explained the reason for the visit. During the complaint investigation visit for complaint # 22-AS-20240701161612, LPA observed that the See Something, Say Something Poster (PUB 475) is posted in a hallway next to the elevator and measures 8 1/2 by 11 inches. LPA informed Jerry Perez that the poster must be 20 by 26 inches and posted in the main entry way of the facility. An exit interview was conducted and a copy of the report along with a technical violation (LIC 9102) was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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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