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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006220
Report Date: 03/06/2023
Date Signed: 03/06/2023 11:42:34 AM

Document Has Been Signed on 03/06/2023 11:42 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:MARY'S LOVING CARE AFACILITY NUMBER:
306006220
ADMINISTRATOR:HAN, XUFACILITY TYPE:
740
ADDRESS:341A 16TH PLACETELEPHONE:
(646) 549-5035
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 5DATE:
03/06/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Xu HanTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Xu Han, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 08/01/2022. This is a change of ownership with persons in care. This is the second pre-licensing inspection. Please see LIC809 dated 02/15/2023.

During the initial pre-licensing inspection, LPA and AP observed that there was no patio cover or outdoor seating for residents and AP agreed to purchase and install outdoor seating and an umbrella to provide seating and shade for the residents.

During today’s inspection, LPA and AP inspected the facility and observed that outdoor seating and an umbrella had been installed to provide seating and shade for the residents. LPA confirmed that the issue noted during the initial pre-licensing inspection has been addressed.

LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. Component III was completed with AP during the initial pre-licensing inspection. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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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