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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002673
Report Date: 05/31/2022
Date Signed: 05/31/2022 11:47:36 AM


Document Has Been Signed on 05/31/2022 11:47 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:
05/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Benjamin MocanTIME COMPLETED:
11:20 AM
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Licensing Program Analysts (LPAs) Ruth Martinez made an unannounced site visit to the facility on this date for the purpose of delivering an amended report originally issued on 05/24/2022. In order for report to reflect proper Administrator name.

LPA arrived at facility was met by Administrator Benjamin Mocan outside of the facility due to Administrator no longer having control of the property.

Exit interview was conducted with Administrator and a copy of this LIC809 report was left with the Administrator, along with copies of amended reports.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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