306005334-6-20-2023-22-AS-CDPO-CSYNLP-20230620103351

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005334
Report Date: 06/20/2023
Date Signed: 06/20/2023 10:34:53 AM

Document Has Been Signed on 06/20/2023 10:34 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:	WONDER'S YEARS		FACILITY NUMBER:	306005334
ADMINISTRATOR:	JUAN M. GARCIA TRUJILLO		FACILITY TYPE:	740
ADDRESS:	24301 BARK STREET		TELEPHONE:	(949) 215-4087
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 2	DATE:	06/20/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Staff- Mariadelos Trujillo Cruz		TIME COMPLETED:	10:55 AM

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

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 06/02/2023. LPA De Perio explained reason for visit, was greeted and granted entry by staff on duty (S1) Mariadelos Trujillo Cruz.

On 06/02/22 facility failed to complete an individual written admission agreement. Deficiency cited under Title 22 Regulation 87507(a) pertaining to Admission Agreements has been CLEARED. LPA De Perio reviewed proof of understanding regarding the regulation cited and reviewed resident charts, of which it was observed that the current residents have signed admission agreements. Licensee has complied with the terms of the POC.

An exit interview was conducted with S1 Cruz and facility administrator Juan Garcia Trujillo via telephone call.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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