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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005694
Report Date: 11/01/2021
Date Signed: 11/01/2021 12:36:48 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:DEL'S HAVENFACILITY NUMBER:
306005694
ADMINISTRATOR:MANALO, DIANNAFACILITY TYPE:
740
ADDRESS:29835 ANDREA WAYTELEPHONE:
(949) 418-3222
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Dianna ManaloTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA and staff toured the facility. Administrator Dianna Manalo arrived at 12:00 pm. LPA and Administrator toured facility. Smoke detectors/carbon monoxide detectors tested operational. LPA toured the backyard. No bodies of water observed. The exit gate is operational. There is a seating area with a table, an umbrella and chairs for residents to sit outside. The kitchen is clean and had a 2 day supply of perishable food and a 7 day supply of non-perishable food on hand. LPA interviewed staff and residents. LPA observed all of the bedrooms had the required furnishings. All the bathrooms were clean and operational. No obstacles or hazards observed in or outside of the facility. Facility has a mitigation plan that has been approved. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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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