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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005972
Report Date: 05/21/2021
Date Signed: 05/24/2021 11:06:10 AM

Document Has Been Signed on 05/24/2021 11:06 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, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:SAINT JOSEPH HOME'S FVFACILITY NUMBER:
306005972
ADMINISTRATOR:CRUZ, LEAHFACILITY TYPE:
740
ADDRESS:9371 EL VALLE AVETELEPHONE:
(714) 488-8413
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: DATE:
05/21/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Leah Cruz & Brian EstorbaTIME COMPLETED:
10:30 AM
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Facility Type: RCFE
Application Type: Change of Ownership
Capacity: 6
Census (if any clients in care): 6
Method: Telephone call with CAB
COMP II Participants: Leah Cruz, administrator and Brian Estorba, applicant

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. CAB has been advised to transmit signed LIC 809 with copy of photo ID to CAB.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2021
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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