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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002559
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:07:48 AM

Document Has Been Signed on 03/21/2022 11:07 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LAGUNA PALMS IIFACILITY NUMBER:
306002559
ADMINISTRATOR:MICHAEL G. MILOFACILITY TYPE:
740
ADDRESS:29501 VIA SAN SEBASTIANTELEPHONE:
(949) 429-6397
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Julieta MiloTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Administrator Julieta Milo. LPA explained the reason for the visit. LPA and Administrator toured the facility. Facility has 8 bedrooms (2 are for staff), 7 bathrooms, living room, dining room, kitchen and a two car garage. There is a fountain in the courtyard of the facility. The fountain is empty and has no water. LPA observed the PUB 475 poster (See Something, Say Something poster) is 10 1/2 X 17 inches. LPA observed all resident bedrooms had the required furnishings and were large enough to accommodate the resident and their belongings. LPA observed all bathrooms were clean and operational. Hot water measured 115.3 to 119.6 degrees Fahrenheit. Smoke detectors/carbon monoxide detectors tested operational. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPA and Administrator toured the backyard. There is a small fountain and seating area in the backyard. The exit gate is operational. No obstacles or hazards observed in the backyard. LPA and Administrator toured the garage. The garage is kept locked and used to store extra supplies. Facility has submitted the mitigation plan. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided. Administrator refused to sign the report (LIC 809).
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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