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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002255
Report Date: 05/26/2022
Date Signed: 05/26/2022 12:26:37 PM


Document Has Been Signed on 05/26/2022 12:26 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:COVINGTON, THEFACILITY NUMBER:
306002255
ADMINISTRATOR:EILEEN LEA DAVISFACILITY TYPE:
741
ADDRESS:3 PURSUITTELEPHONE:
(949) 389-8500
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY:343CENSUS: 180DATE:
05/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Donald "Cash" BensonTIME COMPLETED:
01:00 PM
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
Upon conducting the annual visit, Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin were informed by Executive Director (ED) Cash Benson that on 5/25/22, there was a fire in a Resident 1's (R1) room that began at 8:58 PM. Fire was immediately extinguished and controlled. Resident was moved out of room and transferred to a guest room. Facility took measures of drying R1's room and hallways, post-incident inspection will be conducted prior to resident moving back to room. Resident was not harmed, and no other residents were involved.

LPA De Perio provided ED Regional Office email for reference:

CCLASCPOrangeCountyRO@dss.ca.gov
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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