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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005511
Report Date: 06/30/2021
Date Signed: 06/30/2021 01:18:53 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:MILESTONE ELDER CAREFACILITY NUMBER:
306005511
ADMINISTRATOR:KONTAR, JOHNFACILITY TYPE:
740
ADDRESS:25142 LAS BOLSASTELEPHONE:
(949) 742-0247
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 2DATE:
06/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Levita HoganTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced Case Management visit for the purpose to verify facility closure. LPA arrived at facility, greeted at the door by Levita Hogan, caregiver and granted entry. LPA met with caregiver and explained the nature of the visit. LPA spoke with John Kontar, Administrator via telephone call and explained the nature of the visit.

Upon entry LPA observed a resident sitting outside and informed LPA he was a resident of the facility. Upon entry of the facility LPA observed a resident in the living room resting. LPA took a tour of the physical plant of the facility and observed resident’s bedroom and medication locked and stored in kitchen cabinet. Based on the observation there still remains two residents in care. LPA explained to Licensee and caregiver that until all residents are relocated to another facility, LPA could not initiate a facility closure for the licensee. Caregiver to inform LPA once residents have been relocated. LPA received on June 27, 2021 via email a copy of the annual fee signed indicating Licensee no longer has interest in renewing the license.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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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