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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006344
Report Date: 05/02/2024
Date Signed: 05/02/2024 05:02:25 PM


Document Has Been Signed on 05/02/2024 05:02 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:COGIR OF BREAFACILITY NUMBER:
306006344
ADMINISTRATOR:FAYE, SAMUELFACILITY TYPE:
740
ADDRESS:700 MADISON WAYTELEPHONE:
(714) 681-0105
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:110CENSUS: 38DATE:
05/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Mirian ImTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA met with the Health and Wellness Director Miriam Im and explained the reason for the visit. During the required 10-day visit to begin the investigation into complaint # 22-AS-20240502115044, LPA observed that the See Something, Say Something poster (PUB 475) was not posted in the main entry way of the facility. The PUB 475 poster was posted in the hallway adjacent to the main entry way of the facility next to the mail boxes and elevator. LPA informed the Health and Wellness Director that the PUB 475 poster must be posted in the main entry way of the facility. The Health and Wellness Director stated she understood.

An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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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