<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003841
Report Date: 02/16/2024
Date Signed: 02/16/2024 10:28:41 AM


Document Has Been Signed on 02/16/2024 10:28 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:A PERICLES ELDERLY CARE HOMEFACILITY NUMBER:
306003841
ADMINISTRATOR:LUIS GAITANFACILITY TYPE:
740
ADDRESS:25822 PERICLESTELEPHONE:
(949) 859-2811
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
02/16/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Luis Gatan and Concepcion JimenezTIME COMPLETED:
10:48 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 01/30/2024. LPA was greeted and granted entry into the facility by CEO Concepcion Jimenez and explained the reason for the visit. Administrator Luis Gatan was present as well.

Deficiency cited under Title 22 Regulation 87307(a) pertaining to Maintenance and Operation has been cleared. During the visit, LPA observed the exit gate has been repaired. Licensee has complied with the POC.

Deficiency cited under Title 22 Regulation 87412(c) pertaining to Personnel Records has been cleared. Licensee provided proof of staff training. Licensee has complied with the POC.

LPA observed items on the advisory note given 01/30/2024 have been addressed.




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: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1