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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006153
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:10:57 PM

Document Has Been Signed on 10/10/2023 03:10 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:CARE JANELLAFACILITY NUMBER:
306006153
ADMINISTRATOR:CALANGI, KARMIANFACILITY TYPE:
740
ADDRESS:17072 SAGA DRIVETELEPHONE:
(714) 683-4617
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 5DATE:
10/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Leonora Amorsolo- Administrator
Vergilio Galang- House Manager		TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to conduct a Case Management visit. LPA met with Administrator (Admin) Leonora Amorsolo and explained the reason for the visit. It was established during the staff interviews in connection to Complaint Control Number: 22-AS-20230714131828 that the live-in Staff #1 (S1) does not provide assistance to residents in their Activities of Daily Living (ADLs) in the evenings.

During the course of today's visit, LPA verified on the Personnel Report and through three out of three staff interviews confirming the presence of an additional staff in addition to S1 during the nocturnal hours.

Based on the observations and interviews made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

Due to the Administrator's time constraints, Admin authorized House Manager to sign the report on her behalf.

An exit interview was conducted with House Manager Verigilio Galang, and a copy of this report was provided to the HM at exit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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