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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006430
Report Date: 10/10/2024
Date Signed: 10/10/2024 10:48:24 AM

Document Has Been Signed on 10/10/2024 10:48 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:ANKERTON SUITEFACILITY NUMBER:
306006430
ADMINISTRATOR/
DIRECTOR:		LINGAT, TRISTANFACILITY TYPE:
740
ADDRESS:94192 ANKERTON DRIVETELEPHONE:
(949) 374-2683
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
10/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Camille Santos, administrator
Tristan Lingat, licensee		TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Samer Haddadin made an unannounced visit to the facility to conduct a case management visit. LPAs were greeted and granted entry by facility caregiving staff after introducing themselves and stating the purpose of the visit. Administrator Camille Santos and licensee Tristan Lingat were notified of the visit via telephone and arrived later to assist.

LPAs initially came to the licensed location to conduct an annual visit for license #306005497. However, this license has been inactive since the initial licensing of the present licensed location on June 12, 2024. License 306005497 was verified to be inactive through interviews, review of resident and staff records along with a telephone call to former licensee Ignatius Rusli.

There are currently six residents in care, five of which are receiving hospice care. The current license is observed to be posted. Current administrator certificates are also present on the premises.

Upon reviewing two resident records maintained at the facility, LPAs observed the admission agreement had not yet been updated to reflect the current license number. A Technical Assistance Advisory Note was issued.

At this time, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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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