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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002068
Report Date: 02/08/2021
Date Signed: 02/09/2021 07:25:24 AM

Document Has Been Signed on 02/09/2021 07:25 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:FOUNTAIN VIEW BOARD AND CAREFACILITY NUMBER:
306002068
ADMINISTRATOR:VIVIAN ORTIZ-LUISFACILITY TYPE:
740
ADDRESS:17688 SAN FRANCISCO STREETTELEPHONE:
(714) 963-0026
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: DATE:
02/08/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Micel Reynoso and Vivian Ortiz-LuisTIME COMPLETED:
03:15 PM
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At this informal conference present were: Micel Reynoso and Vivian Ortiz-Luis, LPA Ruth Martinez, Acting RM Marina Stanic, LPM Alisa Ortiz via video conference call due to COVID-19 and pre-cautionary measures.

The purpose of today’s meeting is to discuss the ownership change of the facility and timeline.

During this meeting a discussion regarding the following topics were discussed:

-Change of ownership into new corporation
-Submission of application
-Timeline of submission and completion of application to CAB

LPM Alisa Ortiz will work with The Central Applications Unit to informed them of the application in order to facilitate the change.

An exit interview was conducted with facility representative and a copy of this report was provided to facility representative via email. An electronic email read receipt or response to email indicating as received as confirmation. Facility representative agrees to send a signed copy by email.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2021
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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