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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312828
Report Date: 01/08/2024
Date Signed: 01/08/2024 03:57:15 PM


Document Has Been Signed on 01/08/2024 03:57 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:URQUIZA, KARINAFACILITY NUMBER:
304312828
ADMINISTRATOR:URQUIZA, KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 866-0079
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:14CENSUS: 0DATE:
01/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Karina Urquiza - LicenseeTIME COMPLETED:
04:00 PM
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A case management visit was conducted today at the facility to verify criminal record fingerprint clearance. Upon arrival licensee was not in the facility, 5 minutes later licensee arrived at the facility with 1 minor child, licensee's son. Licensee stated license is currently Inactive and there are no children in care. LPA's Odom and Trinh observed that there wasn't any children in care at the facility. Licensee stated there are 3 adults and 1 minor child living in the home, which are, licensee, 2 adult children and 1 minor child.

LPA's reviewed and explained letter to licensee and provided a copy of the letter. Licensee stated they will communicate with Guardian to submit proper documentation. Adult #1 is not living in the home since 12/2020.

Exit interview was reviewed and read to licensee, Karina Urquiza.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
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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