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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005606
Report Date: 08/15/2022
Date Signed: 08/15/2022 07:06:34 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/15/2022 07:06 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:TERANIMAR HOMECAREFACILITY NUMBER:
306005606
ADMINISTRATOR:EVELYN DELA CRUZFACILITY TYPE:
740
ADDRESS:3166 W TERANIMAR DRIVETELEPHONE:
(714) 723-0129
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 0DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Enrico Demapasok, Tenant , Evelyn DeLaCruz, Administrator and Stephanie Johnson, AdministratorTIME COMPLETED:
03:28 PM
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a Required 1 Year Annual Inspection visit. Upon arriving to facility, LPA Quiroz was greeted by Enrico Demapasok who was watering glass and plants in front yard. LPA Quiroz introduced self. Enrico Demapasok indicated "not speaking English." On or about 2:05pm, LPA Quiroz called and left voicemails for Administrator (AD) Evelyn DeLaCruz and (AD) Stephanie Johnson. While waiting for call back, LPA Quiroz walked around exterior of the facility and did not observe any clients, medical devices but not limited to: walkers or wheelchairs while touring exterior of the facility. LPA Observed property was being utilized as a Family home.
Between 2:21-3:02pm, LPA Quiroz called and spoke to Administrator Evelyn DeLaCruz and Administrator Stephanie Johnson who verified "Facility is no longer operational since May 2022. No residents since May 2022." AD Stephanie Johnson indicated "Licensee is renting the property out to relatives and no longer operating property as a facility for elderly residents. Due to low census, the Licensee's couldn't keep with the expenses and decided to move forward with facility closure and rent property to relatives."

On today's date LPA Quiroz provided (AD) Evelyn DeLaCruz and (AD) Stephanie Johnson consultation on Title 22 California Code Regulations (CCR)85064.2: Administrator Certification Requirements and CCR 85018: Application for License. LPA Quiroz reminded (AD) DeLaCruz and (AD) Johnson of the requirement of applying for new license should Licensee wish to operate a facility once again. (AD) Johnson indicated she understood and in agreement that in order to operate a facility, a new license to operate a facility will be required.

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SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TERANIMAR HOMECARE
FACILITY NUMBER: 306005606
VISIT DATE: 08/15/2022
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Exit interview of today's report conducted via telephone with (AD) Stephanie Johnson. Licensee and/or (AD) Stephanie Johnson not able to sign today's report.

Today's report will be mailed out to Licensee via certify mail. (AD) Johnson agreed to mail and surrender license#306005606 to Community Care Licensing along with signed copy of this report.

Facility closure paperwork will be processed with effective date closed of August 15, 2022.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC809 (FAS) - (06/04)
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