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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006034
Report Date: 09/24/2021
Date Signed: 09/24/2021 10:33:27 AM

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:PHAMILY HOME ELDERLY CARE 2FACILITY NUMBER:
306006034
ADMINISTRATOR:PHAM, CHARLESFACILITY TYPE:
740
ADDRESS:16652 HUGGINS AVETELEPHONE:
(657) 724-9930
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: DATE:
09/24/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Charles PhamTIME COMPLETED:
10:29 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
Method: Telephone call with CAB
COMP II Participants: Charles Pham, administrator/licensee

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 and LIC 808 Mitigation Plan to CAB.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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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