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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004379
Report Date: 05/28/2024
Date Signed: 05/28/2024 10:20:30 AM

Document Has Been Signed on 05/28/2024 10:20 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MOMS AND DADSFACILITY NUMBER:
306004379
ADMINISTRATOR/
DIRECTOR:		ACE JACER EDORA TABLANGFACILITY TYPE:
740
ADDRESS:6177 NORSTADT WAYTELEPHONE:
(714) 883-3140
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
05/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Reca Edora YapTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Jerome Haley arrived to complete the required one-year annual visit that was started May 16, 2024. LPA Haley was greeted and granted entry by staff and explained the reason for the visit.

During the visit, LPA Haley completed a review of staff records, resident records, reviewed resident medications and completed the inspection tool.

As a result of the annual inspection, a Technical Violation was issued for clutter in the backyard. Since the Technical Violation was issued (5.16.24), the clutter and debris have been cleared from the backyard. No further action is needed.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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