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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005452
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:19:39 PM

Document Has Been Signed on 12/15/2021 04:19 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:MERYEMANAFACILITY NUMBER:
306005452
ADMINISTRATOR:ISON, JOMFACILITY TYPE:
734
ADDRESS:26491 ARACENA DRIVETELEPHONE:
(949) 426-1666
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 5CENSUS: 4DATE:
12/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:53 PM
MET WITH:Administrator Jom IsonTIME COMPLETED:
04:30 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) Albert Marin made an unannounced case management visit to deliver the amended report for visit completed last December 14, 2021. LPA met with Administrator (AD) Jom Ison; and stated the purpose of this visit.

LPA Marin conducted an exit interview with AD Ison and copies of this report and that of the amended report were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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