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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005660
Report Date: 06/06/2024
Date Signed: 06/12/2024 07:46:23 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/12/2024 07:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PERICLES HOMEFACILITY NUMBER:
306005660
ADMINISTRATOR:FERNANDEZ, LALAINEFACILITY TYPE:
740
ADDRESS:25752 PERICLES STREETTELEPHONE:
(949) 350-1604
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
10:45 AM
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On June 6, 2024 at 8:30am, Licensing Program Analyst (LPA) Edward Kim attempted to conduct an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted by and granted entry by staff. Administrator Omega Ferrer informed LPA Kim the facility has changed ownership and facility name to Solace Senior Care Home (306006136) effective date October 13, 2022.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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