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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001585
Report Date: 09/23/2021
Date Signed: 09/23/2021 04:59:45 PM

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:LAKEVIEW HOMES MISSION VIEJOFACILITY NUMBER:
306001585
ADMINISTRATOR:ALFONSO VENTURAFACILITY TYPE:
740
ADDRESS:23036 SONOITATELEPHONE:
(949) 583-1213
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:4CENSUS: 3DATE:
09/23/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Sarah Levante TIME COMPLETED:
04:55 PM
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Licensing Program Analysts (LPA) Norman Woodridge conducted an unannounced visit to the facility to conduct a case management visit and to review Coronavirus 2019 (COVID-19) mitigation plan. LPA stated the purpose of the visit, was granted entry by staff 1 (S1), and went through screening procedure upon entering the building.

LPA conducted a tour of the inside and outside of the facility. No deficiencies were noted. LPA spoke to Staff 2 (S2). LPA discussed Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19). LPA discussed Covid-19 Mitigation Plan with S2 and requested a copy of the completed LIC 808 form. A copy of PIN 21-38-ASC was given to S2.

No deficiencies were noted and citations were not issued.

LPA Norman Woodridge conducted an exit interview with S2 and provided her with a copy of this report.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Norman WoodridgeTELEPHONE: (714) 703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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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