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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006530
Report Date: 09/17/2024
Date Signed: 09/17/2024 09:34:54 AM


Document Has Been Signed on 09/17/2024 09:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:FAMILY TIES SENIOR LIVINGFACILITY NUMBER:
306006530
ADMINISTRATOR:RAJPOOT, FAISALFACILITY TYPE:
740
ADDRESS:6096 SHERIDAN WAYTELEPHONE:
(949) 290-1826
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 0DATE:
09/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Faisal Rajpoot & Kamil RajpootTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Jerome Haley made an announced visit to conduct a follow up pre-licensing inspection to ensure all corrections from the initial pre-licensing visit have been completed. LPA Haley was greeted and granted entry by applicants Fasial and Kamil Rajpoot. LPA Haley explained the reason for the visit upon entry.

During a tour of the facility, LPA Haley observed that the following items have been corrected.

1. Ceiling in the garage has been completed. Studs are no longer visible. 2. Exposed wires in the garage have been covered by the finished ceiling and are no longer exposed. 3. Fireplace screen has been placed on the fireplace in the living room. 4. Additional activities and/or games are now available for the residents including Pictionary, Scrabble, and some arts and crafts items.



All items have been corrected. No new deficiencies were observed. The facility is ready for licensure.

Component III was presented to the applicants after the follow up inspection.

An exit interview was conducted, and a copy of this report was provided to applicants Fasial and Kamil Rajpoot.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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