<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004700
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:58:49 PM


Document Has Been Signed on 11/28/2023 02:58 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:QUALITY SENIOR LIVING HOUSE #2FACILITY NUMBER:
306004700
ADMINISTRATOR:MARIA DOLORES D. TENTEFACILITY TYPE:
740
ADDRESS:26791 MORENA DRIVETELEPHONE:
(949) 309-9314
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
11/28/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Ferdinand Inoncillo & Beverly Inoncillo- CaregiversTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jessica Cho continued the visit in conjunction with a complaint investigation in connection to Complaint Control Number: 22-AS-20231101095717. LPA explained the reason for the POC visit to Caregivers Ferdinand Inoncillo and Beverly Inoncillo. At 12:52pm, Administrator authorized Caregiver Ferdinand Inoncillo to sign the report on her behalf.

*Deficiency cited Title 22 Regulations (e)(b)(2) Request a transfer of a criminal record clearance. LPA received proof of clearance and the Acknowledgement of Understanding on November 22, 2023. The Administrator has complied with the POC. The Administrator has been advised via this report to maintain compliance in the item cited on November 7, 2023.

An exit interview was conducted with Caregiver Ferdinand Inoncillo, and a copy of this report including the Letter of Deficiency Citations Cleared were provided at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1