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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005554
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:43:15 PM

Document Has Been Signed on 06/28/2022 12:43 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:DEVOTED HEART CARE HOMES LLCFACILITY NUMBER:
306005554
ADMINISTRATOR:KEVIN CLARKFACILITY TYPE:
735
ADDRESS:26665 AVENIDA SHONTOTELEPHONE:
(818) 384-9331
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 3DATE:
06/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Medical Coordinator Melanie Morris TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA met with Medical Coordinator (MC) Melanie Morris; and stated the purpose of the visit.

After granted entry in the facility, LPA Marin conducted a tour of the interior and exterior portions of the facility. LPA observed MC on the floor with no clients in care. Client 1's room was located in the second floor. After the tour, LPA reviewed the medication, did a file review and phone interview with Administrator Ken Leonard. LPA provided list of documents requested and reviewed them with MC Morris. MC agreed to provide the dpocuments on or before end of business day of 06/28/2022.

No citation was issued on this visit.

Due to time constraints, this visit will be completed at a later time.

LPA conducted phone exit interview with AD Leonard. LPA left copy of this report and list of documents in the facility.



SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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