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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006220
Report Date: 08/19/2024
Date Signed: 08/19/2024 10:24:58 AM

Document Has Been Signed on 08/19/2024 10:24 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:MARY'S LOVING CARE AFACILITY NUMBER:
306006220
ADMINISTRATOR/
DIRECTOR:		HAN, XUFACILITY TYPE:
740
ADDRESS:341A 16TH PLACETELEPHONE:
(949) 200-9378
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 3DATE:
08/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Xiaofen YouTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to gather additional information for an exception request that was made.

During the visit, LPA Haley conducted interviews 4 staff members and 2 residents. Relevant documents were provided.

The information gathered during today’s visit will be reviewed by the department.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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