<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003634
Report Date: 09/20/2021
Date Signed: 09/20/2021 12:24:08 PM

Document Has Been Signed on 09/20/2021 12:24 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:CASA DEL LAGOFACILITY NUMBER:
306003634
ADMINISTRATOR:RIVERO, LOURDESFACILITY TYPE:
740
ADDRESS:27332 ALLARIZTELEPHONE:
(949) 716-4497
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
09/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Administrator Lourdes RiveroTIME COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management to review the Coronavirus 2019 (COVID 19) mitigation of the facility. Staff 1 informed Administrator (AD) Lourdes Rivero. AD arrived in the facility shortly. LPA stated the purpose of the visit.

About 11:07 AM, LPA Marin was granted entry after completing the COVID 19 screening procedure. LPA conducted a tour inside and outside of the facility. LPA observed five in care and two staff members on the floor. With AD Rivero in the facility, LPA discussed the following: Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID 19). LPA also discussed the COVID 19 mitigation plan of the facility.

For this visit, no deficiency was observed or citation was issued.

LPA Marin conducted an exit interview with AD Rivero, and copies of this report and PIN 21-38-ASC were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1