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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006306
Report Date: 01/30/2025
Date Signed: 01/30/2025 09:48:04 AM

Document Has Been Signed on 01/30/2025 09:48 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:CARE CHARLIZEFACILITY NUMBER:
306006306
ADMINISTRATOR/
DIRECTOR:		CALANGI, KARMIANFACILITY TYPE:
740
ADDRESS:17602 AMAGANSETTELEPHONE:
(949) 394-8708
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 5DATE:
01/30/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:42 AM
MET WITH:Joy Bongsol - Caregiver TIME VISIT/
INSPECTION COMPLETED:
09:15 AM
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
On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a plan of correction visit. LPA was greeted and granted entry into the facility by Joy Bongsol and explained the reason for the visit.

At 8:10AM LPA Mendivil toured the facility, reviewed documents and observed the following:

Deficiency cited under Title 22 87506(b)(11) regarding the physician's report for Resident 5 has been cleared LPA Mendivil observed physician's report for R5. Licensee has complied with POC.

Deficiency cited under Title 22 87463(b) regarding updated physician's reports for Resident 4 and Resident 6 has been cleared. LPA Mendivil observed updated physician reports and appraisals. Licensee has complied with POC

Deficiency cited under Title 22 87456(a)(3) regarding physician's report for Resident 2 (R2) has been cleared. LPA Mendivil observed a physician's report, appraisal and admission agreement. Licensee has complied with POC .

Deficiency cited under Title 22 87465(d)(3) regarding usage and notation of PRN has been cleared. Administrator provided MAR for PRNs. Licensee has complied with POC

All other citations noted on visit from 01/17/2025 have been cleared by the Administrator prior to POC visit.

An exit interview was conducted an a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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