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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005983
Report Date: 06/03/2021
Date Signed: 06/03/2021 12:17:31 PM

Document Has Been Signed on 06/03/2021 12:17 PM - 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 PALMA HOMECAREFACILITY NUMBER:
306005983
ADMINISTRATOR:BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:1418 W LA PALMA AVETELEPHONE:
(714) 833-5911
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
06/03/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kathrina BullerTIME COMPLETED:
09:25 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made the announced visit to conduct the second pre-licensing inspection. LPA met with applicant Kathrina Buller. LPA observed the fireplace has a new screen and meets the regulatory requirements. Facility meets Title 22 Division 6 of the California Code of Regulations and is ready to be licensed. LPA explained the process of this application and also about post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the CAU supervisor in Sacramento. Component III was waived during the visit due to applicant is a current licensee for a licensed RCFE facility and in compliance status, supervisor approved. An exit interview was conducted and a copy of this report, LIC809 was explained and provided to applicant Kathrina Buller.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2021
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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