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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700782
Report Date: 03/12/2021
Date Signed: 03/12/2021 03:00:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 4DATE:
03/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Elizabeth Maina, staffTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 03/12/2021 to conduct a case management visit. LPA's temperature was taken prior to entry into the facility and LPA was wearing a mask and cleared prior to going into the field. LPA met with staff, Elizabeth Maina.

LPA conducted an interview with resident (R1) during today's visit.

No deficiencies were cited and a copy of report was emailed to Bob Coleman.

A signed copy of the report to be returned to Community Care Licensing (CCL) by either fax, email, or USPS. Facility should also retain a signed copy.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
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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