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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005599
Report Date:
12/12/2022
Date Signed:
12/12/2022 02:26:35 PM
Document Has Been Signed on
12/12/2022 02:26 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
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
A1 ELDER CARE
FACILITY NUMBER:
306005599
ADMINISTRATOR:
SHAH, BINDI
FACILITY TYPE:
740
ADDRESS:
2538 E LARKSTONE DRIVE #A
TELEPHONE:
(949) 929-5318
CITY:
ORANGE
STATE:
CA
ZIP CODE:
92869
CAPACITY:
6
CENSUS:
6
DATE:
12/12/2022
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Arlene Molina and Leticia Solis
TIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 12/08/2022. LPAs were greeted and granted entry into the facility by Caregiver Arlene Molina and explained the reason for the visit. Caregiver Leticia Solis arrived during the visit.
Deficiency cited under Title 22 Regulation 87202(a) pertaining to Fire Clearance has NOT been cleared. Two residents are residing in the un-permitted room. Facility removed center wall but residents are still in room and room alteration has not been approved by the city. Licensee has NOT complied with the POC. CIVIL PENALTY ASSESSED.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Kimberly Lyman
TELEPHONE:
(714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE:
12/12/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/12/2022
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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