<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005247
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:55:53 PM

Document Has Been Signed on 08/26/2024 04:55 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:FULLERTON PLAZA GUEST HOMESFACILITY NUMBER:
306005247
ADMINISTRATOR/
DIRECTOR:		MANGURAY, SEANFACILITY TYPE:
740
ADDRESS:3931 MADONNA DRIVETELEPHONE:
(657) 378-9603
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 6CENSUS: 3DATE:
08/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Ana SantosTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On August 26, 2024, 12:45pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Inspection visit following up on an Incident Report received on Friday August 23, 2024 by the Orange County Regional Office. LPA Kim was greeted and granted entry by House Manager (HM) Ana Santos. Assistant Administrator (AA) Gerald Dia was contacted over the phone and was not able to be at the facility.

LPA Kim toured indoor and outdoor of the physical plant with HM Santos. LPA Kim did not observe any health and safety concerns. LPA conducted one (1) resident interview, four (4) staff interviews, and an audit of resident record (R1) file.

No deficiencies cited during this visit.

An exit interview was conducted and a copy of this report was provided to House Manager Ana Santos

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1