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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005732
Report Date: 10/24/2022
Date Signed: 10/24/2022 10:15:57 AM


Document Has Been Signed on 10/24/2022 10:15 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:ASSISTACARE ROSSMOORFACILITY NUMBER:
306005732
ADMINISTRATOR:MACKENZIE, EMALEEFACILITY TYPE:
740
ADDRESS:3022 SALMON DRTELEPHONE:
(562) 342-9071
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 3DATE:
10/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Evelyn Alfaro- CaregiverTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an inactive telephone number on file. LPA was greeted and granted entry into facility by Caregiver Evelyn Alfaro.

There are 3 residents present during today's visit. LPA Mendivil toured the home and notated no health and safety concerns.

During the visit, LPA obtained new updated phone number. LPA called Licensee Emalee Mackenzie and left a voicemail to advise to notify CCLD in writing regarding updated facility phone number. LPA Mendivil called Administrator James Hart and left voicemail to update facility phone number in writing and provide corrected facility mailing address.


No deficiencies noted during today's visit. An exit interview was 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: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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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