<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005322
Report Date: 11/21/2024
Date Signed: 11/21/2024 11:56:38 AM

Document Has Been Signed on 11/21/2024 11:56 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ACTIVCARE AT YORBA LINDAFACILITY NUMBER:
306005322
ADMINISTRATOR/
DIRECTOR:		ELVA LEDESMAFACILITY TYPE:
740
ADDRESS:4725 VALLEY VIEW AVETELEPHONE:
(714) 577-8005
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 80CENSUS: 41DATE:
11/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Marketing Director- Shannen BuckholzTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On November 21, 2024, at 9:15am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on an incident report that was self reported from the facility. LPA Kim was greeted and granted entry by staff. LPA explained the purpose of the visit to Marketing Director Shannen Buckholz. During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility maintained at a comfortable temperature for the residents in care. LPA obtained Staff Roster, Resident Roster, and R1’s records which includes the Physician’s Report, Admission’s Agreement, Emergency Information, Consent Forms, Incident Reports, and Appraisal and Needs/Service Plan. LPA conducted three staff interviews and attempted two staff phone interviews.

No deficiencies were observed during this visit.

An exit interview was conducted, and a copy of this report was provided to the Marketing Director Shannen Buckholz.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1