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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 12/13/2021
Date Signed: 12/13/2021 02:42:24 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: 6DATE:
12/13/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Erin RehbeinTIME COMPLETED:
03:00 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 12/07/2021. LPA was greeted and granted entry into the facility by Administrator Erin Rehbein and explained the reason for the visit.

At 2:15 PM, LPA toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 87203 pertaining to Fire Safety has been cleared. During today's visit, both exit gates are unlocked. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia, Inaccessible Items, has been cleared. All noted items were observed to be secured. Licensee has complied with the terms of the POC.


Advisory note dated 12/07/2021 indicated training records were missing for Staff 6. LPA reviewed completed training records for the staff during today's visit.


Exit interview was conducted and a copy of the report will be emailed to Administrator due to technical difficulties..
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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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