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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000589
Report Date: 07/07/2021
Date Signed: 07/07/2021 02:23:48 PM

Document Has Been Signed on 07/07/2021 02:23 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BRIGITTE'S VILLA REGINA HOMEFACILITY NUMBER:
306000589
ADMINISTRATOR:MARK FISKFACILITY TYPE:
740
ADDRESS:24331 SPARTANTELEPHONE:
(949) 770-2702
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Administrator Mark Fisk TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced collateral visit to this facility. LPA met with Administrator Mark Fisk and stated the purpose of this visit.

On June 29, 2021, Community Care Licensing Division (CCLD) Orange Office received a letter from Administrator Mark Fisk requesting for an increase in hospice waiver in favor of the facility. CCLD reviewed the compliance history of the facility. On June 30, 2021, CCLD approved the request to increase the hospice waiver for four.

LPA Marin discussed with AD Mark Fisk the terms and conditions of the hospice waiver. LPA provided AD with the updated license for the facility.

LPA Marin conducted an exit interview with AD M. Fisk, Copies of this report, letter of approved hospice waiver increase and updated license were left with AD.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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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