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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003416
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:06:43 PM


Document Has Been Signed on 08/18/2022 04:06 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:CAPSTONE GUEST HOME IIFACILITY NUMBER:
306003416
ADMINISTRATOR:ELVIE HAWKFACILITY TYPE:
740
ADDRESS:17841 COLLINS AVENUETELEPHONE:
(714) 997-1953
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY:6CENSUS: DATE:
08/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Elvie HawkTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit for the purpose of a facility closure. LPAs were greeted and granted entry into the facility by Licensee Elvie Hawk and explained the reason for the visit.


On June 1, 2022, LPA Lyman received notification from Licensee of intent to close facility effective 08/01/2022. Facility had two residents as of letter date. Both residents have since passed. LPAs toured the facility with Licensee and observed facility is vacant except for Licensee and former caregiver renting a room in the backyard. Licensee surrendered license to LPA during visit and Licensee was provided department letter confirming forfeiture of license.








Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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