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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000408
Report Date: 08/04/2022
Date Signed: 08/04/2022 12:50:18 PM


Document Has Been Signed on 08/04/2022 12:50 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LAKE FOREST COUNTRY HOME #2FACILITY NUMBER:
306000408
ADMINISTRATOR:RIVAS, CARMEN T.FACILITY TYPE:
740
ADDRESS:25231 MAMMOTH CIRCLETELEPHONE:
(949) 472-3811
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
08/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Staff on Duty - Elizabeth FerrerTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted a continuation of the Case Management visit which took place on 6/28/22. During today's visit, 2 staff were on duty, who contacted facility administrator (AD) Carmen Rivas about visit. AD Rivas was unavailable but provided consent for staff on duty (S1) to receive and sign report.

LPA De Perio also obtained a copy of the Sheriff's report submitted by AD Rivas and reviewed the necessary documents.

During this visit, LPA De Perio initiated an interview with resident (R1) to discuss about the incident that took place. R1 stated “I put a stop on the payment of the check, but Sherri told me she ripped it up and did not process it and I believe her.”

R1 also informed LPA De Perio that she has checked her bank account and there were no indications that the check was ever processed.

After file reviews, interviews and proof that the check has not been processed, this incident has been resolved.



There were no deficiencies issued during this Case Management visit. No citation was issued during this visit.

An exit interview was conducted with Licensee/Administrator Carmen Rivas via phone, and S1 and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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