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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005455
Report Date: 02/16/2022
Date Signed: 02/16/2022 12:34:11 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/16/2022 12:34 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:ADELANTO COVENANT CARE 2FACILITY NUMBER:
306005455
ADMINISTRATOR:CARDELLA, JOSEPHFACILITY TYPE:
740
ADDRESS:24911 HENDON STREETTELEPHONE:
(949) 916-2871
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 0DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Joeph CardellaTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing a required inspection. LPA arrived at facility and observed there was remodeling being done to the facility. LPA spoke to the workers and was advised a caregiver was inside. LPA met with the caregiver and was advised there was no residents in the facility since September 2021. LPA advised Administrator that he needs to notify the Department when there are changes in the facility. LPA observed there are no residents in care at the facility. Licensee will contact Community Care Licensing (CCL) to inform of when they are ready to accept new residents or if there are any changes with the license.

At this time there were no deficiencies to report in the facility. As noted above, Licensee will contact CCLD once residents are being admitted. In an effort to update the facility file, the Administrator is required to submit to the licensing agency a copy of the following:

- An updated Personnel Report (LIC 500).

This report was reviewed with administrator and a copy of this LIC809 report was provided

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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