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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006166
Report Date: 10/04/2024
Date Signed: 10/04/2024 08:16:32 AM

Document Has Been Signed on 10/04/2024 08:16 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:INNER CIRCLE ASSISTED LIVING #1, LLCFACILITY NUMBER:
306006166
ADMINISTRATOR/
DIRECTOR:		LIN, ERICFACILITY TYPE:
740
ADDRESS:18332 SERRANO AVETELEPHONE:
(714) 331-7950
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 6CENSUS: 5DATE:
10/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Marie Luciene "Yen" David, Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
08:30 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to amend a civil penalty report assessed on September 10, 2024. LPA met with Marie Luciene "Yen" David.

LPA was informed caregiver is associated and background cleared. LPA read and delivered amended form to Administrator Designee, Yen David and a copy of this report and LIC421BG was left with the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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