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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 09/08/2022
Date Signed: 09/08/2022 01:43:42 PM


Document Has Been Signed on 09/08/2022 01:43 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:JONNADA, LAKSHMIFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 12DATE:
09/08/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Lakshmi JonnadaTIME COMPLETED:
12:35 PM
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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 08/29/2022. LPA was greeted and granted entry into the facility by Administrator Lakshmi Jonnada and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87211(a)(1)(B) pertaining to Reporting Requirements has been cleared. Licensee reported the incident via LIC 624. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87508(a)(1-3) pertaining to Register of Residents has been cleared. Licensee has provided a Register of Residents to LPA. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87705(f)(1) pertaining to Care of Persons with Dementia. Knives are secured during today's visit. Licensee has complied with the terms of the POC.



Exit interview conducted and a copy of this report was left at the facility.




SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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