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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003665
Report Date: 05/23/2022
Date Signed: 05/23/2022 10:54:04 AM


Document Has Been Signed on 05/23/2022 10:54 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:DEL SOL TRES ELDERLY CARE HOMEFACILITY NUMBER:
306003665
ADMINISTRATOR:JIMENEZ, ELIZABETHFACILITY TYPE:
740
ADDRESS:26452 VIA DEL SOLTELEPHONE:
(949) 357-6255
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
05/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Jonathan MayorgaTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Albert Marin and Celine De Perio made an unannounced visit to this facility. LPAs met with Administrator (AD) Jonathan Mayorga; and stated the purpose of this visit.

For this visit, LPAs Marin and De Perio conducted a tour of the facility. LPAs observed that all walls were torn down for renovation; and did not observe any resident in care. Per AD Mayorga, all six residents were transferred to affiliated licensed facilities. AD Mayorga surrendered copy of the facility license on site. LPAs Marin and De Perio discussed with AD that in the event that the Licensee decides to offer care and supervision services in this location in the future, he needs to apply for a license to CCLD before admitting new residents. AD agreed. The facility is rendered closed effective May 23, 2022.

For this visit, no citation was issued.

LPAs Marin and De Perio conducted an exit interview with AD Mayorga and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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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