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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006280
Report Date: 05/08/2023
Date Signed: 05/09/2023 07:12:00 AM


Document Has Been Signed on 05/09/2023 07:12 AM - 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:SHASTA RESIDENTIAL CAREFACILITY NUMBER:
306006280
ADMINISTRATOR:DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:16274 SHASTA STTELEPHONE:
(714) 300-4540
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 0DATE:
05/08/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kevin Dino DinhTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Lydia Martinez conducted this announced continuation of Pre-licensing visit to ensure the facility made the necessary correction required from the Pre-licensing visit inspection on 05/04/2023. LPA Martinez met with Applicant Kevin Dino Dinh and both toured the facility.

Applicant was to knock down the built-in room in the garage that was not drawn on the approved floor plan.

On 05/04/2023, LPA Martinez noted that the application’s approved Fountain Valley Fire Department (FVFD) Fire Clearance did not match the structure. Garage had a built in room that was not drawn on the floor plan that was approved by FVFD on 02/28/2023. Applicant stated room in the garage was already there when he leased the home.

Applicant opted to remove the walls/room. The item identified for correction during initial Pre-licensing visit of 05/04/2023 is now corrected. With the above correction completed the facility's physical plant meets requirements of Title 22 Regulations.

All items reviewed during the visit are in compliance. Facility appears to be ready for licensure based on LPA's evaluation. An exit interview was conducted with Applicant and a copy of this report will be sent to the email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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