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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313540
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:26:55 AM


Document Has Been Signed on 03/16/2022 11:26 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:BENSON, MARINAFACILITY NUMBER:
304313540
ADMINISTRATOR:BENSON, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 606-5814
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:14CENSUS: 12DATE:
03/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee Ms. Benson, MarinaTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Desai, Ketki conducted an unannounced Case Management-Other inspection at the above Large Family Child care home.

Initially there were two Licensee's (Ms.Benson, Marina & Ms.Lisnyak,Iryna), in April 2021 at the request of
Ms. Benson, Marina, co-licensee Ms. Lisnyak,Iryna was removed and a new License was issued with only one name.

Now Ms. Benson has requested to remove her name as a Licensee and add Ms. Lisnyak, Iryna back as the Licensee.

LPA have received the required documents including proof of ownership establishing her stay at the family child care home.
LPA toured the four bedroom home, during the tour of the home it was confirmed Ms. Lisnyak,Iryna is the resident at the home and is also working with the Day care children in care.

New License with the change of Licensee shall be issued upon management approval.

Notice of Site visit was posted.

Exit interview held and Appeal rights were presented to Licensee. Ms. Benson, Marina.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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