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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003644
Report Date: 06/06/2023
Date Signed: 06/07/2023 07:29:47 AM


Document Has Been Signed on 06/07/2023 07:29 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: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: 0DATE:
06/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eloisa TolentinoTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Lydia Martinez conducted a Case Management visit for the purpose of verifying facility closure. LPA met with Eloisa Tolentino and explained the reason for today’s inspection. Licensee Maria Pagkatipunan was not available but visit was discussed via telephone.

The Department was informed on 06/02/2023 that the facility was closing effective immediately and that the facility had no residents. The last resident left the facility on 05/30/2023. Staff surrendered the facility’s license to LPA during today’s inspection. The reason for today's inspection is to confirm the closure of the licensed facility.

LPA toured the facility with Tolentino and observed no residents in care. LPA observed the home to be empty and found no evidence the home is operating as a licensed facility. LPA observed that the facility is no longer operating as a licensed facility and is closed. LPA to provide the forfeiture letter to Licensee via email.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report will be sent to email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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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