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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006149
Report Date: 10/13/2022
Date Signed: 10/13/2022 01:21:25 PM


Document Has Been Signed on 10/13/2022 01:21 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:CARE CONNECTIONFACILITY NUMBER:
306006149
ADMINISTRATOR:GILBERT, ERICFACILITY TYPE:
740
ADDRESS:416 S JENNIFER LANETELEPHONE:
(714) 289-2273
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 4DATE:
10/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eric Gilbert TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced case management visit to gather additional details on the dry Koi Pond observed during the pre-licensing visit.

LPA Haley was greeted and granted entry by Administrator (AD) Eric Gilbert, and explained the reason for today's visit.

During the visit LPA Haley and AD Gilbert measured the gate surrounding the in front of the Koi Pond. The gate and Koi Pond is elevated 10 inches off the ground. The top of the gate measured 5 ft 6 inches (68 inches) from the ground. AD Gilbert removed the combination lock and placed a child proof cabinet slide lock on the gate.
LPA Haley took pictures of the gate and child proof lock.

AD Gilbert states there is no exact time table for the Koi Pond to be put to use, and will likely remain dry for the next 90 days. If the Koi Pond is ready for use before the 90 days, LPA Haley will be notified.

No deficiencies are bing cited during today's Case Management visit. An exit interview was conducted, a copy of this report was provided to AD Gilbert.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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