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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006306
Report Date: 02/06/2025
Date Signed: 02/07/2025 03:24:45 PM

Document Has Been Signed on 02/07/2025 03:24 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, 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: 0DATE:
02/06/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Marian Mejia- Licensee TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On today's date, Licensing Program Manager (LPM) Alisa Ortiz and Licensing Program Analysts (LPAs) Andrea Mendivil and Fred Arias met with Licensee Marian Mejia and Attorney Clinton Hubbard present via telephone on this day for the purpose of discussing ongoing facility issues.

The following was discussed:
· Concerns regarding recent Annual visit which resulted in 17 citations, 15 Type A and 2 Type B
· Licensee's responsibilities of facility oversight
· Licensee's requirement to assess residents prior to admission and ensure all preadmission paperwork is completed
· Licensee’s responsibility to ensure physical plant is maintained and all construction is reported to CCLD prior to commencing
· Licensee’s responsibility to ensure medications are received, provided and maintained as prescribed

The Licensee Stated as following during today's meeting:
· Licensee will designate a staff as Facility Designated Administrator Back up and provide documentation of LIC 308 by COB on 02/07/2025
- Licensee will provide more oversight at the facility including spending more time at the home and provide updated LIC 500 to reflect Licensee's time at facility and provide documentation by COB 02/07/2025
- Licensee will review and maintain all facility paperwork every 1-2 weeks
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CONT on LIC 809- C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARE CHARLIZE
FACILITY NUMBER: 306006306
VISIT DATE: 02/06/2025
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During the meeting the Department’s Technical Support Program (TSP) was discussed with Licensee. Licensee expressed interest in Technical Support Program (TSP) and has agreed to participate.

An exit interview was conducted with Licensee Marian Mejia and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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