<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607470
Report Date: 05/03/2021
Date Signed: 05/03/2021 11:18:33 AM

Document Has Been Signed on 05/03/2021 11:18 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MAUREEN GUEST HOME #4FACILITY NUMBER:
300607470
ADMINISTRATOR:MCKENZIE, VICTORFACILITY TYPE:
740
ADDRESS:9371 MELBA DR.TELEPHONE:
(714) 539-5146
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 0DATE:
05/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Victor McKenzie, LicenseeTIME COMPLETED:
11:19 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jim August contacted the facility via video-telephone due to COVID-19 and precautionary measures and to commence a case management visit. LPA identified himself and discussed the purpose of the call of the visit with licensee Victor McKenzie.

The purpose of the visit today is to discuss the closure of the facility and confirmation that residents have vacated the property. LPA August obtained a copy of the intent to close letter from the the licensee. The licensee has agreed to mail the original license back to the Orange County Regional Office.

LPA August discussed the four (4) prior residents, (R1, R2, R3 and R4) and confirmed all 4 residents moved out of the facility. LPA inspected the property, all rooms and closets and determined the residents had moved out.
No deficiencies are being cited during today's visit. The facility is ready to be closed.

An exit interview was conducted with licensee McKenzie via video-telephone and a copy of this report was provided to McKenzie via email. McKenzie to sign the report and scan/email back to LPA August within 24 hours.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: James August
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1