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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002673
Report Date: 03/14/2022
Date Signed: 03/14/2022 10:49:27 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/14/2022 10:49 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:MY HOME BOARD & CAREFACILITY NUMBER:
306002673
ADMINISTRATOR:BENJAMIN MOCANFACILITY TYPE:
740
ADDRESS:22305 SAVONATELEPHONE:
(949) 855-9899
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 0DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Benjamin Mocan, AdministratorTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual inspection. LPA arrived at the facility was greeted and granted entry into the facility by Administrator. LPA met with Benjamin Moca, Administrator and explained the nature of the visit.

LPA toured the facility and inspected the physical plant; no residents were observed at the facility. LPA was informed on March 04, 2022 that all resident had been moved out and relocated due to the facility planning to close. Last resident moved out and relocated on February 28, 2022, LPA observed facility was empty. However, LPA was informed there may be a possible change of ownership for the facility. Licensee is currently doing touch up work on the house and there was no furniture observed in the facility. Licensee agrees to contact LPA to inform of the change of ownership or of they will proceed with the facility closure immediately upon decision. LPA informed Licensee that if they decided to do a facility closure one last inspection would have to be conducted, Licensee understood and agreed.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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