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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005550
Report Date: 10/13/2021
Date Signed: 10/13/2021 02:58:53 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:ASPEN VILLAFACILITY NUMBER:
306005550
ADMINISTRATOR:ALAMOUTINIA, MARYAMFACILITY TYPE:
740
ADDRESS:25911 VIA VIENTOTELEPHONE:
(949) 648-9205
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
10/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management. LPA was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. Via phone, LPA spoke to Administrator (AD) Maryam Alamoutinia and stated the purpose of this visit.

On September 15, 2021, LPA Marin conducted a case management visit. LPA observed deficiency and issued a citation per Title 22 Division 6 of the California Code of Regulations. For this visit, LPA reviewed the plan and proof of correction done by the Administrator. LPA accepted the plan of correction and cleared the citation.

LPA Marin also discussed with AD some best practices on screening visitors and essential personnel in relation to the COVID 19 mitigation plan of the facility.

LPA conducted an exit interview with AD Alamoutinia. AD granted permission for staff to receive and sign the report. LPA left copy of this report, letter of citation cleared and latest facility personnel report in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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