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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003644
Report Date: 05/26/2022
Date Signed: 05/26/2022 02:54:48 PM


Document Has Been Signed on 05/26/2022 02:54 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: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: 3DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Eloisa TolentinoTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Eloisa Tolentino and explained the reason for the visit. Caregiver Ricardo Bugay was present as well. Administrator Maria Velez has a current administrator certificate expiring on 12/01/2023.

At 12:55 PM, LPA toured the facility with Caregiver Tolentino. Facility has three residents in care during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. Restrooms have hand washing signs posted. One resident room is currently double occupancy and one is single occupancy. Auditory exit alarms are operational. Facility screens visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility has a visitor sign in sheet. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as department postings including a posted emergency disaster plan. Smoke and carbon monoxide detectors tested operational during today's visit. Fire extinguisher is mounted and charged. At 1:05 PM, LPA observed one burner on the cook top is inoperable. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked, alarmed and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed three resident files during the visit and all files include updated emergency information. All residents and staff are vaccinated for Covid-19.

No deficiencies noted during today's visit. 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: 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)
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