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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006134
Report Date: 09/17/2024
Date Signed: 09/17/2024 11:15:56 AM

Document Has Been Signed on 09/17/2024 11:15 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VIA LA CORUNA MANORFACILITY NUMBER:
306006134
ADMINISTRATOR/
DIRECTOR:		MCKEEVER, KAYLAFACILITY TYPE:
740
ADDRESS:23911 VIA LA CORUNATELEPHONE:
(714) 770-7669
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
09/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Martha Zea- CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On September 17, 2024, at 10:20am, Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim conducted an unannounced case management visit for the purpose of interviewing Resident #1 (R1) in connection to a pending investigation at another licensed facility, Complaint Control Number: 22-AS-20240910152630. LPAs were greeted and granted entry by Caregiver Martha Zea and explained the purpose of the visit. Caregiver Zea notified Administrator (Admin) Bryant So by phone. Administrator Rochel Malaca was also advised of the visit by phone. LPAs spoke to Administrator So explaining the reason for the visit and authorized Caregiver Zea to sign the report on his behalf.

During today's visit, LPAs interviewed R1 and obtained records of R1, such as Physician's Report and Face Sheet.

An exit interview was conducted with Caregiver Martha Zea, and a copy of this report including the LIC811 were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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