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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 08/29/2022
Date Signed: 08/29/2022 12:34:53 PM


Document Has Been Signed on 08/29/2022 12:34 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:
08/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Lakshmi JonnadaTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) 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 08/23/2022. LPA was greeted and granted entry into the facility by Administrator Erin Lakshmi Jonnada and explained the reason for the visit.


*Deficiency cited under Title 22 Regulation 87355(e)(2) pertaining to Criminal Background Clearance Association has NOT been cleared. Administrator is still not associated to the facility. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ASSESSED




Exit interview conducted and a copy of this report will be emailed to the Administrator.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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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