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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005974
Report Date: 05/20/2022
Date Signed: 05/20/2022 10:49:52 AM

Document Has Been Signed on 05/20/2022 10:49 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:LA HABRA PLAZAFACILITY NUMBER:
306005974
ADMINISTRATOR:DIA, GERALDFACILITY TYPE:
740
ADDRESS:2630 RAINIER WAYTELEPHONE:
(562) 905-0034
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 6CENSUS: 4DATE:
05/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:David WilliamsTIME COMPLETED:
10:29 AM
NARRATIVE
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During today's unannounced annual inspection Licensing Program Analyst (LPA) did not observe 2-day supply of perishable and a 7-day supply of non-perishable foods; a Deficiency was cited on this date
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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Document Has Been Signed on 05/20/2022 10:49 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/20/2022 at 10:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LA HABRA PLAZA
FACILITY NUMBER: 306005974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
HSC
87555(a)

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(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents.
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Facility needs to have and maintain a 2-day supply of perishable foods and a 7 day of non-perishable foods at all times.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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