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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005477
Report Date:
11/01/2022
Date Signed:
11/01/2022 10:49:56 AM
Document Has Been Signed on
11/01/2022 10:49 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:
JC HOME FOR SENIORS-CARE
FACILITY NUMBER:
306005477
ADMINISTRATOR:
PARUNGAO, MARIA E
FACILITY TYPE:
740
ADDRESS:
15332 SHASTA LANE
TELEPHONE:
(714) 622-5118
CITY:
HUNTINGTON BEACH
STATE:
CA
ZIP CODE:
92647
CAPACITY:
6
CENSUS:
6
DATE:
11/01/2022
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
10:45 AM
MET WITH:
Janet Benebicdo
TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Janet Benebicdo
Per review annual was conducted on 10/24/2022
No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
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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