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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 08/19/2021
Date Signed: 08/19/2021 12:25:20 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 LIVINGFACILITY NUMBER:
306005773
ADMINISTRATOR:REHBEIN, ERINFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: DATE:
08/19/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shahzad Kahn and Adrienne SheltonTIME COMPLETED:
11:45 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
Acting Regional Manager (ARM), Alisa Ortiz, and Licensing Program Analyst (LPA) Kimberly Lyman, conducted an informal office meeting via teams application with Licensee Shahzad Khan and Business Partner/Consultant Adrienne Shelton, to discuss responsibilities of the Licensee and staffing issues.

ARM and LPA spoke with Khan & Shelton in regards to staffing issues and designation of responsibilities within the facility in response to an employee leaving the facility residents without supervision on the night of 08/17/2021. The employee left the facility without notifying the Administrator after the relieving staff member was a no-show and failed to call out. The residents were left alone in the facility without supervision from 10:50PM to 7AM. One of the residents is listed as a two person assist and only one person was scheduled per shift. According to Khan and Shelton, they are aware of the staffing issue and are working to fulfill staffing needs at the facility.

During today’s informal visit, ARM, LPA, Licensee Khan and Business Partner Shelton discussed the staffing plan for the next two weeks and that facility will retain a minimum of two staff for every shift. Licensee will provide the completed staffing schedule for the next two weeks by close of business today. Following the provided schedule the Licensee will provide a monthly staffing schedule to the Department until staffing concerns are resolved. The Licensee and Business Partner anticipate the staffing concerns should be resolved within four to six weeks time. In the interim the facility will utilize health care organizations to assist with staffing. The Licensee is in communication with at least two health care organizations at this time. The Licensee has scheduled an in service for staff from 8/20/2021 to 8/22/2021 in regards to the facility policy about call outs as well as the need to remain on shift until a reliever is present.

This report was discussed with Licensee Khan and Business Partner Shelton. A copy of this report was provided to Licensee Khan.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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