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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005565
Report Date: 11/23/2022
Date Signed: 11/23/2022 10:53:35 AM


Document Has Been Signed on 11/23/2022 10:53 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:AK AND DAVID SENIOR CAREFACILITY NUMBER:
306005565
ADMINISTRATOR:CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:24302 BARK STTELEPHONE:
(949) 677-3394
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 5DATE:
11/23/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Staff Duty-Mary Rose SagumTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced collateral visit to facility in conjunction with complaint: 22-AS-20221107095603. LPA De Perio was greeted and granted entry by staff on duty, who contacted facility administrator (AD) Mary Jean Catacutan about visit. AD Catacutan was unable to be present during time of visit, but provided consent for staff on duty (S1) Mary Rose Sagum to receive, and sign report.

For today's visit, there are a total of 5 residents in care of which 2 are on hospice, and two staff members present.

LPA De Perio was provided further information regarding complaint.

At this time, no deficiencies were issued, and no citations issued.

An exit interview was conducted with S1 and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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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