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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306006188
Report Date:
06/02/2023
Date Signed:
06/02/2023 02:47:19 PM
Document Has Been Signed on
06/02/2023 02:47 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:
SAMANTHA'S HOME
FACILITY NUMBER:
306006188
ADMINISTRATOR:
ZANO, ROMEO
FACILITY TYPE:
735
ADDRESS:
1640 W. CAMILE PLACE
TELEPHONE:
(714) 836-4571
CITY:
SANTA ANA
STATE:
CA
ZIP CODE:
92703
CAPACITY:
6
CENSUS:
5
DATE:
06/02/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:35 PM
MET WITH:
Susan Kabiling - Direct Support Professional
TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced Case Management visit to Samantha's Home. LPA Velazquez was allowed entry into the facility and met with Direct Support Professional (DSP) Susan Kabiling. The purpose of this Case Management visit was in reference to a complaint with Complaint Control Number: 22-AS-20210216143528.
There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Direct Support Professional Susan Kabiling and a copy of this report was provided at the time of this visit.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
Patricia Velazquez
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/02/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/02/2023
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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