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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005675
Report Date: 09/21/2021
Date Signed: 09/21/2021 10:31:22 AM

Document Has Been Signed on 09/21/2021 10:31 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:SANDY CREEK CARE HOME IIFACILITY NUMBER:
306005675
ADMINISTRATOR:MEJIA, JONALYNFACILITY TYPE:
740
ADDRESS:21596 AUDUBON WAYTELEPHONE:
(562) 301-8265
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
09/21/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jonalyn MejiaTIME COMPLETED:
10:30 AM
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
Licensing Program Analyst Michelle Reed arrived at the facility to conduct a Case Management visit. Upon arrival, LPA met with Jonalyn Mejia. Resident's were watching resting, watching tv, and doing a puzzle. On 6/10/21 the Orange County Fire Authority granted a fire clearance for 6 non-ambulatory resident's of which 1 may bedridden. The bedridden room is Room #2.

A new License updating the changes will be sent to Ms. Mejia. The clearance will also include the hospice waiver for 6.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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