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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306006178
Report Date:
12/07/2024
Date Signed:
12/07/2024 09:09:50 AM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
12/07/2024 09:09 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:
POLLY'S PLACE
FACILITY NUMBER:
306006178
ADMINISTRATOR/
DIRECTOR:
VALENCIA, POLLY
FACILITY TYPE:
740
ADDRESS:
2143 W. FIR AVE.
TELEPHONE:
(949) 412-2579
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
6
CENSUS:
6
DATE:
12/07/2024
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:
ADMINISTRATOR POLLY VALENCIA
TIME VISIT/
INSPECTION COMPLETED:
09:02 AM
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This LIC809 is generated to update the LIC9099 D page for the previous annual done on 11/23/2024.
SUPERVISORS NAME
:
Ulysses Coronel
LICENSING EVALUATOR NAME
:
Jose Calderon
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/07/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
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