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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006167
Report Date: 06/14/2023
Date Signed: 06/14/2023 04:14:31 PM

Document Has Been Signed on 06/14/2023 04:14 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:LE-SA RESIDENTIAL CARE INCFACILITY NUMBER:
306006167
ADMINISTRATOR:LEE, JAMIEFACILITY TYPE:
735
ADDRESS:6622 MOUNT RIPLEY DRIVETELEPHONE:
(657) 214-2932
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 5DATE:
06/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jamie LeeTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Case Management evaluation. On this day, LPA met with Administrator (AD) Jamie Lee Land reason for visit was explained.

The Licensee requested an increase in capacity from 5 to 6 clients. Fire Clearance was granted by Orange County Fire Authority on 04/06/2023 for five (5) ambulatory and one (1) non-ambulatory in bedroom #3. The increase has been granted. On this day, LPA toured the facility and noted client rooms are private, all have plenty of space and the required furnishings such as bed, night stand, dresser, storage space, lamp/light and chair.

LPA Martinez to provide the facility with a new license.

An exit interview was conducted and a copy of this report will be sent to email on file along with new license.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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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