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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006350
Report Date: 01/08/2024
Date Signed: 01/08/2024 11:19:02 AM

Document Has Been Signed on 01/08/2024 11:19 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ARBOR ON THE GREENFACILITY NUMBER:
306006350
ADMINISTRATOR:MARK FISK / BRIGITTE FISKFACILITY TYPE:
740
ADDRESS:24182 PASEO DEL CAMPOTELEPHONE:
(949) 998-9191
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 0DATE:
01/08/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mark Fisk, Applicant/Administrator
Brigette Fisk, Applicant/Administrator		TIME COMPLETED:
11:11 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Mark Fisk, Applicant/Administrator
Brigette Fisk, Applicant/Administrator
Interview Method: Telephone interview

On January 8, 2024 at 10:00 AM, Applicants/Administrators participated in COMP II. Identification of the applicants/administrators was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicants/administrators confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducts by both Applicants/Administrator. Report sent via email and informed to return sign copy by end of business day to CAB.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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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