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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006166
Report Date: 08/29/2022
Date Signed: 08/29/2022 03:34:04 PM

Document Has Been Signed on 08/29/2022 03:34 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:INNER CIRCLE ASSISTED LIVING #1, LLCFACILITY NUMBER:
306006166
ADMINISTRATOR:LIN, ERICFACILITY TYPE:
740
ADDRESS:18332 SERRANO AVETELEPHONE:
(714) 331-7950
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 6CENSUS: DATE:
08/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Eric LinTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a follow up pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Eric Lin. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 03/04/2022 for a capacity of five non-ambulatory and one bedridden resident.

During the visit, LPA toured the facility and observed the following:
  • Facility has an ample supply of emergency water stored in the garage.
  • All facility restrooms have hand washing signs.
  • Facility provided proof of purchase of outdoor seating with a ship date of 08/31/2022.






Facility has complied with the corrections and is ready to be licensed.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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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