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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005974
Report Date:
05/20/2022
Date Signed:
05/20/2022 10:49:52 AM
Document Has Been Signed on
05/20/2022 10:49 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:
LA HABRA PLAZA
FACILITY NUMBER:
306005974
ADMINISTRATOR:
DIA, GERALD
FACILITY TYPE:
740
ADDRESS:
2630 RAINIER WAY
TELEPHONE:
(562) 905-0034
CITY:
LA HABRA
STATE:
CA
ZIP CODE:
90631
CAPACITY:
6
CENSUS:
4
DATE:
05/20/2022
TYPE OF VISIT:
Case Management - Deficiencies
UNANNOUNCED
TIME BEGAN:
10:28 AM
MET WITH:
David Williams
TIME COMPLETED:
10:29 AM
NARRATIVE
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During today's unannounced annual inspection Licensing Program Analyst (LPA) did not observe 2-day supply of perishable and a 7-day supply of non-perishable foods; a Deficiency was cited on this date
SUPERVISOR'S NAME:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
05/20/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/20/2022
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
2
Document Has Been Signed on
05/20/2022 10:49 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
LA HABRA PLAZA
FACILITY NUMBER:
306005974
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
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(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
05/20/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/20/2022
LIC809
(FAS) - (06/04)
Page:
2
of
2