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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004267
Report Date: 01/20/2021
Date Signed: 01/20/2021 11:07:56 AM

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:GOLDEN COAST SENIOR LIVING #13FACILITY NUMBER:
306004267
ADMINISTRATOR:VILLARREAL, AL/USHAFACILITY TYPE:
740
ADDRESS:24372 AUGUSTIN STREETTELEPHONE:
(949) 533-4025
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
01/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Usha VillarrealTIME COMPLETED:
10:30 AM
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At 10:00 AM, Licensing Program Analyst (LPA), Mike Barrett, conducted a virtual visit at this facility for the purpose of verifying the transfer of all residents in order that the facility may be closed. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with Licensee, Usha Villarreal.

At 10:05 AM, LPA Barrett and Licensee Villarreal toured the interior and exterior of the facility. LPA verified that there were no residents in the facility. LPA also verified that this facility is scheduled for a pre-licensing inspection following this verification for closure.

An exit interview was conducted with the Licensee and a hard copy of this report was provided to the Licensee via email for signature.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021
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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