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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006179
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:01:01 PM

Document Has Been Signed on 09/20/2024 03:01 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:FOOTHILL RESIDENTIAL CAREFACILITY NUMBER:
306006179
ADMINISTRATOR/
DIRECTOR:		QUEZADA, JOSHUAFACILITY TYPE:
735
ADDRESS:8404 E FOOTHILL STTELEPHONE:
(562) 756-6463
CITY:ANAHEIMSTATE: CAZIP CODE:
92808
CAPACITY: 4CENSUS: 3DATE:
09/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Joshua QuezadaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow-up on an incident report received by Community Care Licensing on September 11, 2024. LPA met with Administrator (AD) Joshua Quezada and explained the reason for the visit.

Incident report dated September 10, 2024, indicated an incident occurred off-site involving Client 1 (C1) while they were out independently in the community.

During today’s visit, LPA interviewed C1, and reviewed and obtained pertinent documentation, such as C1’s Treatment Recommendations/Medical Info form, Physician Report (LIC 602), and Individual Program Plan (IPP). LPA informed AD that subsequent visits and document requests could be required regarding the incident and AD stated they understood.

An exit interview conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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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