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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306006116
Report Date:
10/18/2023
Date Signed:
10/18/2023 01:38:21 PM
Document Has Been Signed on
10/18/2023 01:38 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
FLOWERS FAMILY CARE
FACILITY NUMBER:
306006116
ADMINISTRATOR:
MARTINEZ, JONATHAN
FACILITY TYPE:
740
ADDRESS:
1009 W 20TH ST.
TELEPHONE:
(949) 274-0634
CITY:
SANTA ANA
STATE:
CA
ZIP CODE:
92706
CAPACITY:
6
CENSUS:
3
DATE:
10/18/2023
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
01:10 PM
MET WITH:
Dominga Santillian
TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 09/14/2023. LPA was greeted and granted entry into the facility and explained the reason for the visit.
*Deficiency cited under Title 22 Regulation 87412(c) pertaining to Staff Training Records has been cleared. Licensee provided proof of training. Licensee has complied with the POC.
*Deficiency cited under Title 22 Regulation 87405(a) pertaining to Administrator Qualifications has been cleared. Licensee provided proof of correction. Licensee has complied with the POC.
Licensee has been advised to maintain compliance in all items previously cited.
An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Kimberly Lyman
TELEPHONE:
(714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE:
10/18/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/18/2023
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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