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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 12/22/2022
Date Signed: 12/22/2022 09:30:47 AM


Document Has Been Signed on 12/22/2022 09:30 AM - 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: 13DATE:
12/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Lilly RamosTIME COMPLETED:
09:46 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 12/14/2022. LPA was greeted and granted entry into the facility by Caregiver Lilly Ramos and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. Exit gate is unlocked, operational and opens from the inside. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87468.1(a)(2) pertaining to Personal Rights has been cleared. Facility is taking staff and resident temperatures daily. Licensee has complied with the POC.

Advisory note indicated facility to obtain tweezers for first aid kit. LPA observed tweezers during the visit.

Licensee has been advised to maintain compliance in all items previously cited.



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: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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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