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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 12/04/2024
Date Signed: 12/04/2024 01:45:58 PM

Document Has Been Signed on 12/04/2024 01:45 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:GRACES HOMEFACILITY NUMBER:
306005470
ADMINISTRATOR/
DIRECTOR:		MAI, NGOCFACILITY TYPE:
740
ADDRESS:2152 S JETTY DRTELEPHONE:
(714) 553-1166
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: DATE:
12/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:36 PM
MET WITH:Ngoc MaiTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Samer Haddadin made an unannounced visit to conduct a case management. LPA met with Administrator Mai Ngoc and stated the purpose of this visit. .

The purpose of this case management visit was to amend the annual visit report dated back on November 25th, 2024 and re-print deficiencies and the original 809 annual inspection report and the 809-D pages.

An exit interview was conducted and a copy of this report was provided to AD at the facility,

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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