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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004250
Report Date: 05/01/2024
Date Signed: 05/01/2024 10:04:59 AM


Document Has Been Signed on 05/01/2024 10:04 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ESPIRITU GUEST HOME IVFACILITY NUMBER:
306004250
ADMINISTRATOR:CELIA B. MENDOZAFACILITY TYPE:
740
ADDRESS:2602 N. GRAND AVENUETELEPHONE:
(714) 997-9453
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:8CENSUS: 0DATE:
05/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Roy Borja and Administrator Celia MendozaTIME COMPLETED:
10:20 PM
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On today's date, Licensing Program Analyst's (LPA) Jenifer Tirre and Faith La conducted an unannounced visit to the facility to verify facility closure and to ensure there are no Residents in care that require care and supervision residing at the facility. LPA's were greeted and granted entry with Staff. LPA's met with Licensee Roy Borja and Administrator Celia Mendoza.

On February 28, 2024, the Orange County Regional Office received notification that licensee has decided to permanently close the facility at this time. Licensee indicated the last resident residing at the facility moved out on April 23, 2024 and has not admitted any residents since.

On today's visit, LPA Tirre, LPA La and Licensee Borja toured the inside and outside of the facility. No Residents were observed during today's visit. Based on today's observations, no signs of facility operation at this time.

LPA Tirre requested facility license as part of the closure process. LPA Tirre informed Licensee Borja of licensing procedures for future facility operation if desired. Licensee indicated understanding.

An exit interview was conducted with Licensee Borja and a copy of today's report was provided at exit.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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