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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003644
Report Date: 10/21/2021
Date Signed: 10/21/2021 09:03:59 AM

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:MIRABEL BY THE SEA VFACILITY NUMBER:
306003644
ADMINISTRATOR:CEZAR PAGKATIPUNANFACILITY TYPE:
740
ADDRESS:249 CALLE EMPALMETELEPHONE:
(949) 498-2488
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:6CENSUS: 4DATE:
10/21/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Eloisa TolentinoTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 09/28/2021. LPA was greeted and granted entry into the facility by Caregiver Eloisa Tolentino and explained the reason for the visit. There are 4 residents present during today's visit.

At 8:55 AM, LPA toured the facility with Caregiver Eloisa Tolentino and observed the following:

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Buildings and Grounds has been cleared. During today's visit, there are no bugs present, screen has been repaired and outside visitation area is clean. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87705(c)(5) pertaining to Medical Assessment has been cleared. Licensee provided proof of updated medical assessment. Licensee has complied with the terms of the POC.



Licensee has been advised to maintain all items especially those that were previously deficient in the facility in accordance with Title 22 Regulations. Copy of this report was provided to the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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