Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312418
Report Date: 04/21/2017
Date Signed 04/21/2017 04:14:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LEE, HEASOOKFACILITY NUMBER:
304312418
ADMINISTRATOR:LEE, HEASOOKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 768-6756
CITY:ANAHEIMSTATE: CAZIP CODE:
92808
CAPACITY:14CENSUS: 11DATE:
04/21/2017
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Heasook Lee-LicenseeTIME COMPLETED:
04:30 PM
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LPA Taylor conducted a visit to the facility to deliver a copy of the Evaluation Report which was completed
yesterday, 4/20/17. The report was not given to the Licensee yesterday 4/20/17 due to a computer glitch making the report inaccessible to print out.

Licensee was reminded upon receipt of a Type A deficiency, licensee shall post and provide copies of this report to parents/guardians of children in care and to parents/guardians of children newly enrolled at the facility during the next 12 months. Licensee is to keep acknowledgement receipt signed by parents in each child’s file.

Exit interview was conducted. Report and deficiencies were reviewed during inspection. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Andrea TaylorTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2017
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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