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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006109
Report Date: 01/18/2022
Date Signed: 01/18/2022 11:26:52 AM

Document Has Been Signed on 01/18/2022 11:26 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 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:GOLDEN LIFE MANOR IFACILITY NUMBER:
306006109
ADMINISTRATOR:NUNEZ, LORENZIFACILITY TYPE:
740
ADDRESS:2315 E. PURITAN LANETELEPHONE:
(562) 544-9167
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 5CENSUS: 5DATE:
01/18/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lorenzi Nunez, AdministratorTIME COMPLETED:
11:00 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 5
Census (if any clients in care): 0
COMP II Participants: Lorenzi Nunez, Administrator
Interview Method: Telephone interview


On January 18, 2022 at 10:15 AM, Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator/Licensee confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Administrator understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator. Report sent via PDF email and Administrator will return signed copy.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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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