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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005987
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:02:56 PM

Document Has Been Signed on 08/26/2022 12:02 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ATLANTA HOUSEFACILITY NUMBER:
306005987
ADMINISTRATOR:LOPEZ, MARTIN J.FACILITY TYPE:
735
ADDRESS:2204 S ATLANTA STTELEPHONE:
(714) 539-0696
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: DATE:
08/26/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:TIME COMPLETED:
12:03 PM
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From: Baldwin, Gina@DSS
Sent: Monday, November 15, 2021 11:04 AM
To: CDSS CCL ASCP Clinical Referral <CCLASCPClinicalReferral@dss.ca.gov>
Subject: Plan of Operation for ICF Applications Archer 1, 2, & Atlanta

Hello,

Please see attached Plan of Operation for ICF Applications Archer 1, 2, & Atlanta. Thank you

Gina Baldwin

From: Baldwin, Gina@DSS
Sent: Wednesday, September 8, 2021 2:01 PM
To: Cunanan, Myra@dss <Myra.Cunanan@dss.ca.gov>
Cc: Neeley, Darla@dss <Darla.Neeley@dss.ca.gov>; Grace, Shelly@DSS <Shelly.Grace@dss.ca.gov>
Subject: RE: ICF Applications Archer 1, 2, & Atlanta

Hello,

Please see attached. Thank you

Gina Baldwin
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Gina Baldwin
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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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