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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004687
Report Date: 10/20/2022
Date Signed: 10/20/2022 11:20:20 AM


Document Has Been Signed on 10/20/2022 11:20 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ADRIANA'S SENIOR CARE LIVINGFACILITY NUMBER:
306004687
ADMINISTRATOR:RICHARD MENDOZA, JR.FACILITY TYPE:
740
ADDRESS:25392 ADRIANA STREETTELEPHONE:
(949) 273-5625
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kevin MendozaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Martinez made this unannounced Case Management visit in for the purpose of discussing facilities annual fees that are over due. LPA arrived to the facility was greeted at the door by Kevin Mendoza, Administrator and granted entry. LPA met with Administrator and explained the nature of the visit.

Facility's annual fees have not been paid since August 2022 and are past due and it is imperative that annual fees and late fees be paid as soon as possible to avoid the forfeiture of the license. In an effort to assist with the payment, LPA provided a copy of "Facility Transaction History, which contains PIN number, and can be used to pay the balance immediately at CCLD's website http://www.ccld.ca.gov/.

Administrator at the time of visit was able to pay the annual fees and late fees. LPA introduced herself and informed Administrator that I have been assigned as the new Licensing Program Analyst (LPA) to monitor the facility. LPA accompanied by Administrator took a tour of the physical plant of the facility.

No deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with Administrator and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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