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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006273
Report Date: 05/10/2023
Date Signed: 05/11/2023 07:01:47 AM

Document Has Been Signed on 05/11/2023 07:01 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:EPIC ASSISTANCE CARE HOME #2FACILITY NUMBER:
306006273
ADMINISTRATOR:MESDJIAN, LIZAFACILITY TYPE:
740
ADDRESS:25464 VIA ESTUDIOTELEPHONE:
(949) 218-7268
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
05/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Peter AzizTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted this announced continuation of Pre-licensing visit to ensure the facility made the necessary correction required from the Pre-licensing visit inspection on 04/05/2023. LPA Martinez met with Designated Staff Peter Aziz and both toured the facility.

On 04/05/2023, LPA noted Fire Clearance was granted for 5 Ambulatory and 1 non-Ambulatory Residents on 01/26/2023. Facility had 6 non-Ambulatory residents residing at the facility which would continue to reside after the change of ownership. LPA explained that based on Fire Clearance approved and residents residing in the facility, a new LIC200 with Floor Plan requesting 6 non-Ambulatory would need to be submitted to the Application Specialist and that a new Fire Clearance would be needed.

A new Fire Clearance for 6 non-Ambulatory was granted on 04/27/2023.

The item identified for correction during initial Pre-licensing visit of 04/05/2023 is now corrected. With the above correction completed the facility's physical plant meets requirements of Title 22 Regulations.

All items reviewed during the visit are in compliance. Facility appears to be ready for licensure based on LPA's evaluation. An exit interview was conducted with Designated Staff Aziz and a copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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