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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003898
Report Date: 10/08/2021
Date Signed: 10/08/2021 01:57:09 PM

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:VIA TERCERO HOMESFACILITY NUMBER:
306003898
ADMINISTRATOR:ALEXANDER D. GABATFACILITY TYPE:
740
ADDRESS:22645 VIA TERCEROTELEPHONE:
(949) 305-7357
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
10/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Alexander Gabat, AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted this case management visit to follow up on a 30-day notice received on September 27, 2021. LPA arrived to the facility was greeted and granted entry by Administrator. LPA met with Alexander Gabat, Administrator and explained the nature of the visit.

During the visit LPA Martinez reviewed R1’s file. LPA noted that 30-day notice was served to R1 on September 19, 2021. LPA reviews all documents for accuracy of notice given to R1. Based on the information observed 30- day notice contains the required information to support the notice. R1 since the notice has complied with monthly dues, however other reasons still fall within required guidelines for section 87224 Eviction procedures. LPA advised Administrator to continue communicating the status surrounding the issue with R1. Administrator agrees to keep LPA informed and updated.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator and a copy of the LIC809 and LIC811 was provided and left at the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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