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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006237
Report Date: 10/27/2022
Date Signed: 10/27/2022 03:09:16 PM

Document Has Been Signed on 10/27/2022 03:09 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ASPEN VILLA IIFACILITY NUMBER:
306006237
ADMINISTRATOR:ALAMOUTINIA, MARYAMFACILITY TYPE:
740
ADDRESS:25411 CHAMPLAIN ROADTELEPHONE:
(949) 648-9205
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 0DATE:
10/27/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maryam Alamoutinia- Applicant/AdministratorTIME COMPLETED:
03:00 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
Facility Type: RCFE
Application Type: INITIAL
Capacity: 6
Census (if any clients in care): 0

COMP II Participants: Maryam AlamoutiniaApplicant/Administrator)
Interview Method: Telephone interview with CAB

During COMP II, Applicant/Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Applicant and Administrator qualifications
3. Staffing requirements & Training
4. Program policies - restricted/prohibited health conditions; abuse reporting, incident reporting to CCLD; food service management; emergency procedures; activities programs
5. Grievances, Complaints, Community resources
6. Application document review and technical assistance- Criminal record clearance; Health screening; Fire clearance; First aid/CPR certificate; Administrator certificate; Financial verification; Compliance history; Control of property
SUPERVISORS NAME: Tracy Thompson
LICENSING EVALUATOR NAME: Ricmar Soriano
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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