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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003858
Report Date:
06/10/2024
Date Signed:
06/10/2024 09:44:10 AM
Document Has Been Signed on
06/10/2024 09:44 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
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ST. FRANCIS' HOME CARE
FACILITY NUMBER:
306003858
ADMINISTRATOR/
DIRECTOR:
RAYMOND MENDOZA
FACILITY TYPE:
740
ADDRESS:
23822 VIA NAVARRA
TELEPHONE:
(949) 916-9957
CITY:
MISSION VIEJO
STATE:
CA
ZIP CODE:
92691
CAPACITY:
6
CENSUS:
5
DATE:
06/10/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:
Raymond Mendoza
TIME VISIT/
INSPECTION COMPLETED:
09:58 AM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by administrator Raymond Mendoza.
On this day LPA Tea amended LIC809-D dated 06/06/2024. LPA reviewed amended report with Administrator.
An exit interview was conducted with the administrator. A copy of this report and amended LIC809-D was provided to the facility.
SUPERVISORS NAME
:
Alisa Ortiz
LICENSING EVALUATOR NAME
:
Michael Tea
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/10/2024
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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