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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005810
Report Date:
06/23/2021
Date Signed:
06/23/2021 10:03:41 AM
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:
DEVOTED FAMILY CARE HOME
FACILITY NUMBER:
306005810
ADMINISTRATOR:
PICENO, CASSANDRA
FACILITY TYPE:
740
ADDRESS:
12041 GILBERT ST
TELEPHONE:
(949) 381-9225
CITY:
GARDEN GROVE
STATE:
CA
ZIP CODE:
92841
CAPACITY:
6
CENSUS:
0
DATE:
06/23/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:01 AM
MET WITH:
Casssandra Piceno
TIME COMPLETED:
10:10 AM
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LPA August called AD Casssandra Piceno at 714-949-1351. They still do not have any staff or residents at the facility. The facility was licensed during the Covid Pandemic and they do not intend to open anytime soon. LPA is at the facility and the home is under construction and vacated.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 703-2857
LICENSING EVALUATOR NAME:
James August
TELEPHONE:
714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2021
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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