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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005673
Report Date:
03/24/2021
Date Signed:
03/24/2021 02:14:09 PM
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:
OAKMONT OF HUNTINGTON BEACH
FACILITY NUMBER:
306005673
ADMINISTRATOR:
AYALA, ROSA
FACILITY TYPE:
740
ADDRESS:
18922 DELAWARE STREET
TELEPHONE:
(657) 204-4600
CITY:
HUNTINGTON
STATE:
CA
ZIP CODE:
92648
CAPACITY:
111
CENSUS:
71
DATE:
03/24/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:34 PM
MET WITH:
Administrator, Rosa Ayala
TIME COMPLETED:
02:09 PM
NARRATIVE
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Licensing Program Manager (LPM) Alisa Ortiz and Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced virtual visit to the facility via Microsoft Teams for the purpose to review a Conditional Exemption Approval. LPM Ortiz and LPA Tirre discussed and reviewed the exemption approval conditions with Administrator Rosa Ayala as below:
This exemption is approved with the following conditions:
1.Does not transport clients
2. The individual does not violate any licensing laws and regulations
3. The individual does not engage in conduct that indicates that he/she may pose a risk to the health and safety of any individual who is or may be a client
4.The individual does not fail to disclose a conviction even if it occurred before the exemption was granted.
5. The individual is not convicted of a subsequent crime
Administrator Ayala initialed an acknowledgement of each condition. Administrator Ayala confirmed that the facility will act in accordance with the approval exemption's conditions. LPA Tirre is to send a copy of Conditional Exemption Approval letter to Administrator Ayala. An exit interview was conducted with Administrator Ayala. This LIC 809 Report was signed by LPA Jenifer Tirre. A copy of this report will be sent vial email to Administrator Ayala who agrees to sign the report and return via email.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Jenifer Tirre
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/24/2021
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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