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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 CAREFACILITY NUMBER:
306006116
ADMINISTRATOR:MARTINEZ, JONATHANFACILITY TYPE:
740
ADDRESS:1009 W 20TH ST.TELEPHONE:
(949) 274-0634
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:6CENSUS: 3DATE:
10/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Dominga SantillianTIME 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (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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