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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001960
Report Date: 11/19/2024
Date Signed: 11/19/2024 09:58:09 AM

Document Has Been Signed on 11/19/2024 09:58 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ECLC - WAKE FOREST VILLAFACILITY NUMBER:
306001960
ADMINISTRATOR/
DIRECTOR:		ANGELITA DAVIDFACILITY TYPE:
740
ADDRESS:233 WAKE FOREST RD.TELEPHONE:
(714) 434-9489
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
11/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Angelita David - LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:13 AM
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On 11/19/2024, LPA Mason arrived at the facility for the purpose of amending deficiencies cited on 10/30/2024 as part of the Department's investigation into complaint #22-AS-20241021103457. LPA was greeted and granted entry by facility staff and met with Angelita David, Licensee.

LPA amended the LIC809-D to update the section cited to: 87468.1(a)(15). LPA stated to staff that the plan of correction would not change.

LPA observed no resident mail in the facility staff room during the inspection. LPA cleared the deficiency during the visit. A copy of this report, deficiency page, appeal rights and clear letter were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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