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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006113
Report Date: 03/08/2022
Date Signed: 03/09/2022 08:04:08 AM

Document Has Been Signed on 03/09/2022 08:04 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MILES PLACE OF FOUNTAIN VALLEY 2FACILITY NUMBER:
306006113
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:9367 SISKIN AVENUETELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: DATE:
03/08/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Avendano, Reiner & Cruz, MarkTIME COMPLETED:
04:00 PM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6
Method: Telephone call Applicant/Administrator
COMP II Participants: Avendano, Reiner - applicant & Cruz, Mark - Administrator

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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