<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005773
Report Date:
11/03/2020
Date Signed:
11/03/2020 02:46:29 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 LIVING
FACILITY NUMBER:
306005773
ADMINISTRATOR:
CSUKARDI, ANITA
FACILITY TYPE:
740
ADDRESS:
3105 W. ORANGE STREET
TELEPHONE:
(714) 229-0069
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92804
CAPACITY:
30
CENSUS:
12
DATE:
11/03/2020
TYPE OF VISIT:
Prelicensing
ANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
Licensee Shazad Khan
TIME COMPLETED:
11:30 AM
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 Analysts (LPAs) Criss Trinidad and Patricia Velazquez conducted an announced visit via phone FaceTime virtual technology to Family Choice Senior Living due to the Coronavirus Pandemic and precautionary measures. LPAs Trinidad and Velazquez conducted the visit with Licensee Shazad Khan. The purpose of today's subsequent Pre-Licensing visit was to follow-up on the issues that were present during the initial Pre-Licensing visit dated 08/4/2020. The following issues were observed and required correction:
Repair or replace inoperable stove top burners
Install grab bars for bathroom #1
An exit phone interview was conducted with Licensee Shazad Khan and a copy of this report was signed by LPA Criss Trinidad. This report will be sent via email to Mr. Khan who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Mr. Khan agrees to return the signed copy within 24 hours.
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 748-2936
LICENSING EVALUATOR NAME:
Criss Trinidad
TELEPHONE:
(714) 321-8277
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2020
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
1