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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005986
Report Date: 01/13/2022
Date Signed: 01/13/2022 10:21:11 AM

Document Has Been Signed on 01/13/2022 10:21 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:ACTIVCARE LAGUNA HILLSFACILITY NUMBER:
306005986
ADMINISTRATOR:SHETTER, TODD A.FACILITY TYPE:
740
ADDRESS:25200 PASEO DE ALICIATELEPHONE:
(858) 565-4424
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 72CENSUS: 0DATE:
01/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Patricia Miller, Ececutive DirectorTIME COMPLETED:
10:25 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
Licensing Program Analyst (LPA) Ruth Martinez made an unannounced site visit to the facility on this date for the purpose of delivering an amended pre-licensing report originally issued on 12/21/2021. Due to have the report reflect proper signal system: Delayed Egress System in place. Signal system for pendants/call buttons that are in place.

LPA arrived at facility was greeted at the door by Executive Director and granted entry. LPA explained the nature of today's visit to facility representative.

Exit interview was conducted with facility representative and a copy of this LIC809 report was left with the facility representative, along with copies of amended reports.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
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