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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005599
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:40:30 AM


Document Has Been Signed on 12/15/2022 11:40 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:A1 ELDER CAREFACILITY NUMBER:
306005599
ADMINISTRATOR:SHAH, BINDIFACILITY TYPE:
740
ADDRESS:2538 E LARKSTONE DRIVE #ATELEPHONE:
(949) 929-5318
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: DATE:
12/15/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:J Shah and Bindi ShahTIME COMPLETED:
10:55 AM
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An informal virtual meeting was held on Microsoft teams at Orange County Adult and Senior Care Regional Office in Orange. The informal meeting process was explained to Licensee.
At this informal conference, present were: Regional Manager Marina Stanic, Licensing Program Manager Luz Adams, Licensing Program Analyst (LPA) Kimberly Lyman, Licensee J Shah and Administrator Bindi Shah. The purpose of the meeting was to discuss actions moving forward regarding the altered room in the facility.

The following was discussed during the meeting:
  • LPA Lyman to contact Code Enforcement to obtain in writing clear instructions on the steps to obtain city approval and fire clearance for room #5 on the facility floor plan.
  • Due to the compromised room #5, Licensee agrees to relocate residents residing in room #5.
  • Facility to rearrange facility rooms to accommodate shared rooms for residents currently residing in room #5.
  • Facility to notify resident's responsible parties in writing of relocation of residents to either a shared room or hotel.
  • Facility to provide pictures or a tour via FaceTime to LPA for approval of re-arranged rooms.








License agrees to consult with the department regarding the ongoing process to obtain city approval and fire clearance for room #5.

Exit interview conducted and a copy of this report will be emailed to Licensee.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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