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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005599
Report Date: 12/19/2022
Date Signed: 12/19/2022 09:28:40 AM


Document Has Been Signed on 12/19/2022 09:28 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: 5DATE:
12/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Leticia Solis - caregiver, Bindi Shah- Administrator TIME COMPLETED:
09:45 AM
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Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit to conduct a case management health check in conjunction with a Plan of Corrections visit. LPAs were greeted and granted entry into the facility by Leticia Solis. Administrator Bindi Shah arrived at 8:48 AM, Licensee J Shah arrived at 9:10 AM.

During the inspection, LPAs and Leticia toured the facility. Residents in care appeared to be safe, no imminent health and safety hazards were observed. LPAs observed residents relaxing in their respective rooms. LPAs observed residents to be well groomed and no visible injuries noted.

No deficiencies were cited during this visit. An exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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