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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371247
Report Date: 01/05/2022
Date Signed: 01/05/2022 10:38:44 AM

Document Has Been Signed on 01/05/2022 10:38 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MILESTONES MONTESSORI OF LAKE FORESTFACILITY NUMBER:
304371247
ADMINISTRATOR:PATOPOFF, JAMIEFACILITY TYPE:
850
ADDRESS:23222 LAKE CENTER DRIVETELEPHONE:
(949) 830-9999
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 194TOTAL ENROLLED CHILDREN: 194CENSUS: 95DATE:
01/05/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Director Ms. Patopoff, Jamie TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Desai, Ketki conducted an unannounced Case Management Licensee initiated inspection at the site today for the purpose of adding one room and removing another room.

However the facility is not ready with the actual room and toilet set up for the new room, needs additional time approximately three weeks for the completion.

LPA shall conduct the inspection upon completion of the complete room and toilet set up within the next 3 weeks, as indicated by the Director on site.

Appeal rights were presented and Notice of Site visit was posted.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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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