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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005692
Report Date:
09/19/2023
Date Signed:
09/19/2023 02:32:51 PM
Document Has Been Signed on
09/19/2023 02:32 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:
SILVERADO SENIOR LIVING-TUSTIN HACIENDA
FACILITY NUMBER:
306005692
ADMINISTRATOR:
ERIN LIGHT
FACILITY TYPE:
740
ADDRESS:
240 E 3RD STREET
TELEPHONE:
(714) 832-7900
CITY:
TUSTIN
STATE:
CA
ZIP CODE:
92780
CAPACITY:
42
CENSUS:
23
DATE:
09/19/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Erin Light - Executive Director
TIME COMPLETED:
02:45 PM
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a collateral visit. LPA was greeted and granted entry into facility by Executive Director Erin Light and explained the reason for the visit.
During the visit LPA Mendivil interviewed Resident 1.
No deficiencies noted.
An exit interview was conducted and a copy of this report and provided.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
09/19/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/19/2023
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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