<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 08/23/2022
Date Signed: 08/23/2022 12:44:54 PM


Document Has Been Signed on 08/23/2022 12:44 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:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306005773
ADMINISTRATOR:HUNDLEY, SHANNONFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 11DATE:
08/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lakshmi JonnadaTIME COMPLETED:
12:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced health and safety case management visit to the facility. LPA was greeted and granted entry into the facility by Administrator Lakshmi Jonnada and explained the reason for the visit.

During the visit, LPA toured the facility, reviewed resident files and spoke with Administrator. Administrator is a new hire at facility. Per interviews conducted, Administrator started working at the facility approximately between July 11-18, 2022. LPA/ Community Care Licensing did not receive any notification of new Administrator or designation of responsibility for time between prior and new administrator. LPA observed Administrator has a current administrator certificate expiring on 02/15/2024. LPA confirmed through Guardian system and phone call to Regional Office that Administrator does not have association to facility. LPA reviewed select files during the visit and all files reviewed contained all required documents. LPA observed and spoke with residents during the visit. Residents are relaxing in rooms or common areas and all appeared clean and taken care of. Facility appears clean and sanitary.



Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy will be emailed due to technical difficulties as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/23/2022 12:44 PM - It Cannot Be Edited

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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306005773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited

1
2
3
4
5
6
7
All facilities shall have a qualified and currently certified administrator. . When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible... This requirement is not being met as evidenced by:
8
9
10
11
12
13
14
Based on observation and interviews conducted, Licensee failed to ensure there was a designation of responsibility issued to LPA during absence of administrator. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/23/2022 12:44 PM - It Cannot Be Edited

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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306005773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2022
Section Cited

1
2
3
4
5
6
7
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
Request a transfer of a criminal record clearance...This requirement is not being met as evidenced by:
8
9
10
11
12
13
14
Based on observation and interview, Licensee failed to ensure Administrator has association to facility. Administrator is not associated to facility and LPA verified through Regional Office and Guardian System, This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED
8
9
10
11
12
13
14
Type B
08/30/2022
Section Cited

1
2
3
4
5
6
7
The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. This requirement is not being met as evidenced by:
8
9
10
11
12
13
14
Based on interviews conducted, Licensee failed to ensure LPA/ Department was notified timely of new administrator. Administrator started working approximately sometime between July 11-18, 2022. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3