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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005254
Report Date:
07/28/2021
Date Signed:
07/28/2021 04:02:19 PM
Document Has Been Signed on
07/28/2021 04:02 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:
EMY'S PLACE OF MISSION VIEJO
FACILITY NUMBER:
306005254
ADMINISTRATOR:
PINERA, DOMINADOR C JR
FACILITY TYPE:
740
ADDRESS:
24176 CARRILLO DRIVE
TELEPHONE:
(949) 273-5987
CITY:
MISSION VIEJO
STATE:
CA
ZIP CODE:
92691
CAPACITY:
6
CENSUS:
4
DATE:
07/28/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Emiliana Pinera
TIME COMPLETED:
04:15 PM
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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 Administrator Emiliana Pinera. LPA and Administrator toured the facility. Smoke detectors and carbon monoxide detector were tested and are operational. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA observed medications are kept locked in a cabinet in the kitchen. The garage is used for storage and kept locked. All 4 resident rooms are clean and have the required furnishings. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. The backyard exit gate is operational. No bodies of water observed. The backyard has two covered sitting areas for residents. No obstacles or hazards observed. Mitigation plan is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of this report provided.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/28/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2021
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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