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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005322
Report Date: 05/14/2020
Date Signed: 06/03/2020 08:47:50 AM

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:ACTIVCARE AT YORBA LINDAFACILITY NUMBER:
306005322
ADMINISTRATOR:ELVA LEDESMAFACILITY TYPE:
740
ADDRESS:4725 VALLEY VIEW AVETELEPHONE:
(714) 577-8005
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:60CENSUS: 39DATE:
05/14/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Elva Spina, Executive DirectorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Kathrina Chin contacted the facility via telephone in order to follow up on an immediate action required and a criminal record exemption needed for Staff 1 (S1). The Immediate Action Required letter is dated April 14, 2020.

LPA spoke with Elva Ledesma, Executive Director who verified that Staff 1 was never hired and is not in the facility premises.


An exit tele-conference was conducted with Elva Ledesma, Executive Director and a copy of this report will be provided via email. Elva Ledesma agreed to confirm the receipt of the document, review the report and returned a signed copy.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2020
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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