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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004292
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:20:18 PM


Document Has Been Signed on 05/17/2022 12:20 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:YORK RETIREMENT HOME IIIFACILITY NUMBER:
306004292
ADMINISTRATOR:DONALD JACOBSONFACILITY TYPE:
740
ADDRESS:27281 CALLE DEL CIDTELEPHONE:
(949) 348-8475
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Doanld JacobsenTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Ruth Martinez made an announced visit to this facility to conduct a case management. LPA meet with Donald Jacobsen, Administrator and explained the nature of the visit.

LPA Martinez conducted a case management visit to York Retirement Homes - 300606398 located 22391 Lombardi, Laguna Hills, CA 92653 in order to conduct a facility closure visit. Due to the Licensee not having control of the property LPA met Administrator at this facility to obtain signatures for verification of facility closure on the property mentioned in this report.

LPA Martinez conducted and exit interview with Administrator and provided a copy to Administrator.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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