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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306006531
Report Date:
05/08/2024
Date Signed:
05/08/2024 03:02:27 PM
Document Has Been Signed on
05/08/2024 03:02 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
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
CROWN VALLEY SENIOR HOME
FACILITY NUMBER:
306006531
ADMINISTRATOR/
DIRECTOR:
AVILA MARIA JASMIN
FACILITY TYPE:
740
ADDRESS:
30471 VIA ALCAZAR
TELEPHONE:
(714) 609-2303
CITY:
LAGUNA NIGUEL
STATE:
CA
ZIP CODE:
92677
CAPACITY:
6
CENSUS:
0
DATE:
05/08/2024
TYPE OF VISIT:
Prelicensing
ANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:
Maria Avila
TIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the second pre-licensing visit. LPA met with applicant Maria Avila.
LPA observed the following items have been corrected. LPA observed four chairs and a table outside. The chairs and table are in a shaded area outside the dining room. LPA observed the screen for the bathroom window in bathroom two has been replaced with a new screen. The new screen has no rips or tears. LPA observed the ceiling vent fan in bathroom two is now operational.
The facility is ready to be licensed. LPA informed the applicant that the final approval will be processed by CAB (Central Applications Bureau) in Sacramento.
Exit interview was conducted and a copy of this report was provided to the applicant.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/08/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/08/2024
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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