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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 12/07/2021
Date Signed: 12/14/2021 03:32:49 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:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306005773
ADMINISTRATOR:REHBEIN, ERINFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 6DATE:
12/07/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Erin Rehbein, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Kevin Saborit-Guasch and Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 09/29/2021. LPAs were greeted and granted entry into the facility by Caregiver S1 and explained the reason for the visit. Administrator Erin Rehbein was called by S1 arrived during the visit.

During the visit, LPA reviewed staff training records.

*Deficiency cited under Title 22 Regulation 87412 (c) pertaining to Training Requirements has been cleared. Administrator provided requested Personnel Report (LIC 500) in addition to shift schedules and complete training records. Licensee has complied with the terms of the POC.

Exit interview was conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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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