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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006691
Report Date: 03/03/2025
Date Signed: 03/03/2025 03:50:17 PM

Document Has Been Signed on 03/03/2025 03:50 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ORANGE SENIOR HOME INC.FACILITY NUMBER:
306006691
ADMINISTRATOR/
DIRECTOR:		KIM, TAE SUNFACILITY TYPE:
740
ADDRESS:4994 VIA ROSATELEPHONE:
(714) 213-4840
CITY:YORBA LINDASTATE: CAZIP CODE:
92887
CAPACITY: 6CENSUS: 0DATE:
03/03/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:TAE SUN KIMTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Component II completion: Successful
Facility Type: RCFE
Application Type: INITL
Capacity: 6
Census : 0
Method: Telephone call with CAB
COMP II Participants: TAE SUN KIM(Administrator/Licensee) & JOSHUA DEGMETICH (Analyst).

Administrator/Licensee participated in COMP II via telephone call with CAB analyst. Identification of the Administrator/Licensee was verified by confirming driver’s license number. During COMP II, Administrator/Licensee confirmed the understanding of Title 22. Component II was successfully completed. Administrator/Licensee was advised to email signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Administrator/Licensee's understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Tammy Edwards
LICENSING EVALUATOR NAME: Joshua Degmetich
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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