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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006221
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:50:56 PM

Document Has Been Signed on 03/11/2025 12:50 PM - 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 BFACILITY NUMBER:
306006221
ADMINISTRATOR/
DIRECTOR:		HAN, XUFACILITY TYPE:
740
ADDRESS:341B 16TH PLACETELEPHONE:
(949) 220-7542
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 3DATE:
03/11/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:26 PM
MET WITH:Marc ZalamedaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for deficiencies issued on 03/06/2025 during the required annual inspection. LPA was greeted and granted entry by staff Marc Zalameda. LPA discussed the purpose of the inspection with staff Zalameda.
LPA toured the facility to check the deficiencies have been corrected. One camera was removed from a resident's room and one camera was removed from the kitchen. A third camera remains in place in the kitchen but has been disconnected until a commercial no audio camera can be installed. LPA observed there were no medications in the kitchen cabinets.
Based on LPA observation on today's visit, the Plan of Corrections has been fulfilled by the assigned POC due date of 03/11/2025, thus clearing the Type B deficiencies CCR 87468.2(a)(1) and 87265(h)(2).
An exit interview was conducted with staff Marc Zalameda and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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