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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006115
Report Date: 12/29/2021
Date Signed: 12/29/2021 10:55:10 AM

Document Has Been Signed on 12/29/2021 10:55 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:T3 ADULT CARE RESIDENTIAL CAREFACILITY NUMBER:
306006115
ADMINISTRATOR:LUU, THIENFACILITY TYPE:
735
ADDRESS:1726 SOUTH LATUS PLACETELEPHONE:
(714) 797-6057
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: DATE:
12/29/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care):
COMP II Participants: Luu, Thien, Applicant, Administrator
Interview Method: Telephone interview		TIME COMPLETED:
10:54 AM
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On 12/29/2021, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Katie Keith
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
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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