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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005743
Report Date:
10/02/2023
Date Signed:
10/02/2023 09:16:49 AM
Document Has Been Signed on
10/02/2023 09:16 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:
ASSURED CARE VILLA
FACILITY NUMBER:
306005743
ADMINISTRATOR:
DOMPREH-MENSAH, THERESA
FACILITY TYPE:
740
ADDRESS:
561 EAST SECOND AVE
TELEPHONE:
(310) 650-4190
CITY:
LA HABRA
STATE:
CA
ZIP CODE:
90631
CAPACITY:
6
CENSUS:
3
DATE:
10/02/2023
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
08:55 AM
MET WITH:
Naomi Mensah
TIME COMPLETED:
09:34 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citation issued on 09/14/2023. LPA was greeted and granted entry into the facility and explained the reason for the visit.
*Deficiency cited under Title 22 Regulation
87355(e)(1) pertaining to Criminal Record Clearance has been cleared. Facility provided proof of correction and staff in question has been disassociated from the facility.
Licensee has complied with the POC.
Licensee has been advised to maintain compliance in any items previously cited.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Alisa Ortiz
LICENSING EVALUATOR NAME
:
Kimberly Lyman
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/02/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/02/2023
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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