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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005889
Report Date: 11/01/2021
Date Signed: 11/01/2021 04:02:16 PM

Document Has Been Signed on 11/01/2021 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:DEL'S HAVEN IIFACILITY NUMBER:
306005889
ADMINISTRATOR:MANALO, DIANNAFACILITY TYPE:
740
ADDRESS:29251 VIA SAN SEBASTIANTELEPHONE:
(949) 258-2063
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 5DATE:
11/01/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Dianna ManaloTIME COMPLETED:
04:17 PM
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
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the post licensing inspection. LPA was greeted and granted entry by Administrator Dianna Manalo. LPA and Administrator toured the facility. LPA observed all bedrooms had the required furnishings. LPA observed the bathrooms were operational and clean. Hot water temperature measured 108.6 degrees Fahrenheit to 109.7 degrees Fahrenheit. All grab bars were secure. LPA observed all showers had no slip mats. LPA observed the garage was used for storage of extra supplies and furniture. The garage is kept secured and off limits to residents. LPA toured the backyard. LPA observed a table under the awning with chairs for residents to sit outside. The exit gate is operational. No bodies of water observed. No obstacles or hazards observed in the backyard. LPA observed the kitchen was clean and organized. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand. LPA observed all the medications were kept locked in the hall closet. All fire extinguishers are fully charged. Smoke detectors/carbon monoxide detectors tested operational. LPA reviewed 2 out of 5 staff files. All staff files had all the required items. LPA reviewed 2 out of 6 resident files. Resident files had the required items. LPA reviewed 2 out of 6 resident medications and medication records, no discrepancies found. LPA consulted with the Administrator concerning reporting requirements and continued Covid-19 mitigation procedures. Facility has a mitigation plan that has been approved. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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