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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006357
Report Date: 09/05/2023
Date Signed: 09/05/2023 10:40:31 AM


Document Has Been Signed on 09/05/2023 10:40 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:LIFE CARE SENIOR MANORFACILITY NUMBER:
306006357
ADMINISTRATOR:AVILA, MARIA JASMINFACILITY TYPE:
740
ADDRESS:10415 AZALEA CIRCLETELEPHONE:
(714) 609-2303
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:6CENSUS: DATE:
09/05/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Jasmin AvilaTIME COMPLETED:
10:30 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): zero
COMP II Participants: Maria Jasmin Avila
Interview Method: Telephone interview

On September 5, 2023, Maria Jasmin Avila, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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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