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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005923
Report Date:
02/23/2023
Date Signed:
02/23/2023 01:37:23 PM
Document Has Been Signed on
02/23/2023 01:37 PM
- 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:
BILLY'S HOUSE
FACILITY NUMBER:
306005923
ADMINISTRATOR:
PERSSON, JACLYN
FACILITY TYPE:
735
ADDRESS:
367 S GREENGROVE DRIVE
TELEPHONE:
(714) 831-1330
CITY:
ORANGE
STATE:
CA
ZIP CODE:
92866
CAPACITY:
4
CENSUS:
3
DATE:
02/23/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:40 PM
MET WITH:
Karry Vallejo - Administrator
TIME COMPLETED:
01:45 PM
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LPA Patricia Velazquez conducted an unannounced visit to Billy's House. LPA Velazquez was allowed entry into the home and met with Staff Florante Adoptante. The purpose of this Case Management visit was to deliver an amended Complaint report with Complaint Control Number: 22-AS-20220908144115. Administrator Karry Vallejo arrived later to assist LPA Velazquez with the visit. During today's visit LPA Velazquez conducted an interview with Administrator Karry Vallejo.
There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Administrator Karry Vallejo and a copy of this report along with the amended report will be emailed to kvallejo@abilitiesoc.org. Due to technical difficulties LPA Velazquez was not able to complete the amendment to the original report and will return at a later time to deliver the amended report.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
Patricia Velazquez
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/23/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/23/2023
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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