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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006413
Report Date: 02/23/2024
Date Signed: 02/23/2024 12:50:00 PM

Document Has Been Signed on 02/23/2024 12:50 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:A TOUCH OF CARE SENIOR HOMEFACILITY NUMBER:
306006413
ADMINISTRATOR:AVILA, MARIA JASMINFACILITY TYPE:
740
ADDRESS:17421 LAURIE LANETELEPHONE:
(714) 609-2303
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: DATE:
02/23/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Jasmin AvilaTIME COMPLETED:
12:00 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Maria Jasmin Avila
Interview Method: Telephone interview

On February 23, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program

2. General Provisions/Administrator requirements

3. Staffing requirements & Training

4. Pre Licensing readiness

SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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