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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006002
Report Date: 05/20/2024
Date Signed: 05/20/2024 10:37:46 AM

Document Has Been Signed on 05/20/2024 10:37 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EASTERSEALS ADULT DAY SERVICESFACILITY NUMBER:
306006002
ADMINISTRATOR/
DIRECTOR:		FAROOQUEE, EVELYNFACILITY TYPE:
775
ADDRESS:1570 E 17TH STREETTELEPHONE:
(714) 672-0866
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 50CENSUS: 55DATE:
05/20/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Maria Vega - AdministartorTIME VISIT/
INSPECTION COMPLETED:
10:52 AM
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On 5/20/2024, LPAs Dwayne Mason Jr. and Michael Tea arrived at the facility to conduct a collateral visit in regards to a complaint at a different facility.

LPAs were greeted and granted entry into the facility by Receptionist Mona Ramirez. LPAs met with Administrator Maria Vega and explained the purpose of the visit.

LPAs interviewed Administrator and collected the following client files: Annual Progress Report, Client Development and Evaluation Report and Individual Program Plan. LPAs also collected contact information for a staff member that has worked with the client in question and attempted to conduct an interview with them. LPAs also attempted to conduct an interview with the client's Service Coordinator.

LPAs reviewed this report with the Administrator and provided a copy.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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