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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005754
Report Date: 08/02/2023
Date Signed: 08/02/2023 10:31:43 AM

Document Has Been Signed on 08/02/2023 10:31 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:MILES PLACE OF FOUNTAIN VALLEYFACILITY NUMBER:
306005754
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:18667 SAN FELIPE STREETTELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Mark Cruz, Administrator (Via telephone) and Analyn Tangonan, Caregiver.TIME COMPLETED:
10:31 AM
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
On today's date, Licensing Program Analyst (LPA) Rosie Quiroz arrived unannounced to the facility to conduct a case management visit to deliver an amended report for a visit conducted on 5/18/2023 from 09:26Am - 12:20pm regarding Complaint Control #22-AS-20230509135044.
During todays visit LPA Quirozmet with Administrator (AD) Mark Cruz via telephone and discussed purpose of today's visit. During today's visit, LPA Quiroz along with Caregiver Tangonan conducted tour of interior and exterior facility premises.
The initial report for complaint control #22-AS-20230509135044 was delivered on 05/18/2023. On today's date, LPA Quiroz reviewed the amended report with (AD) Mark Cruz via telephone and addressed changes on amended report and any concerns and/or questions regarding the amendment of the report.
An exit interview was conducted with (AD) Mark Cruz via telephone and with Caregiver Analyn Tangonan in person, and a copy of this report along with the amended complaint report (LIC 9099) and (LIC 9099-C) documents were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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