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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004054
Report Date: 08/04/2022
Date Signed: 08/04/2022 02:14:46 PM


Document Has Been Signed on 08/04/2022 02:14 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:VICTOR GUEST HOMEFACILITY NUMBER:
306004054
ADMINISTRATOR:AUGUSTUS A. TORRESFACILITY TYPE:
740
ADDRESS:24552 TROY STREETTELEPHONE:
(949) 215-0619
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 2DATE:
08/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Lolita Santiago - Direct Support ProfessionalTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Victor Guest Home. LPA Velazquez was allowed entry into the facility and met with Direct Support Professional (DSP) Lolita Santiago. The purpose of this Case Management visit was to deliver an amended Complaint report with Complaint Control Number 22-NP-20211020110447.





There were no deficiencies issued during this Case Management visit. Due to technical issues, LPA Velazquez was not able to generate this written report at the time of the visit. The report will be emailed to Administrator Augustus Torres. Administrator Torres agrees to print and sign the report and return a signed copy to LPA Velazquez via mail.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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