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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005310
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:00:58 PM

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:QUEEN'S HOME 2FACILITY NUMBER:
306005310
ADMINISTRATOR:MAGHBOULEH, KATAYOUNFACILITY TYPE:
740
ADDRESS:26545 AVENIDA DESEOTELEPHONE:
(949) 716-1907
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
07/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Administrator Katayoun "Kathy" Magbouleh TIME COMPLETED:
03:10 PM
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Licensing Program analyst (LPA) Albert Marin made an unannounced visit in this facility to conduct a case management. Via phone, LPA spoke with Administrator (AD) Kathy Magbouleh and stated the purpose of this visit. The purpose of this visit was to deliver the amended report for annual inspection completed last July 6, 2021. AD gave permission for facility staff to sign and receive the reports.

After delivering the amended report, LPA conducted an exit interview with facility staff, and left copy of this report in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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