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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005361
Report Date: 08/13/2021
Date Signed: 08/13/2021 10:38:00 AM

Document Has Been Signed on 08/13/2021 10:38 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:SPRINGWELL HAVEN, LLCFACILITY NUMBER:
306005361
ADMINISTRATOR:RAMIL DE LOS SANTOSFACILITY TYPE:
740
ADDRESS:2424 FRANCISCO DRIVETELEPHONE:
(949) 524-3484
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 4DATE:
08/13/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Luzviminda EstrellaTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced health and safety case management visit. LPA met with Caregiver Luzviminda Estrella and explained the reason for the visit. There are four residents and three staff present during today's visit. LPA spoke with Administrator Christy Valerio by telephone.

At 10:10 AM, LPA toured the facility with Caregiver Luzviminda Estrella. Facility appears clean and sanitary. LPA observed residents relaxing in the facility. LPA spoke with Resident 1 (R1) who verbalized feeling safe and comfortable at the facility. R1 appeared clean and well taken care of. R1 is residing in a private room with the resident's dog. Facility is utilizing covid precautions and has a check in station at the entrance of the facility.



No health and safety violations noted during visit.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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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