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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005694
Report Date: 10/14/2022
Date Signed: 10/14/2022 10:30:29 AM


Document Has Been Signed on 10/14/2022 10:30 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
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: 5DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Dianna ManaloTIME COMPLETED:
10:36 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA met with Administrator Dianna Manalo. LPA and Administrator toured the facility. The facility is a single story home with 6 bedrooms, 3 bathrooms, kitchen, dining room, living room with a screened fireplace and a two car garage which is kept locked and used for storage. LPA observed a small fountain in the front yard which is 4 feet tall and 2 feet in diameter. The water level in the fountain is 2 inches. LPA toured the kitchen and dining room. LPA observed a two day perishable and a seven day non-perishable food supply on hand. The kitchen and dining are both clean and organized. LPA observed medications are kept locked in a kitchen cabinet. LPA measured the hot water in bathroom one in the hallway and the hot water measured 108.8 degrees Fahrenheit. The bathroom was clean and operational. LPA observed clean linen stored in the hall closet. LPA observed the resident rooms had the required furnishings and had enough space to accommodate the residents and their belongings. LPA and Administrator toured the garage. LPA observed the garage is kept locked and inaccessible to residents. The garage is used to store extra food and supplies. LPA and Administrator toured the backyard. There is a covered patio with seating for residents. LPA observed a fountain in the backyard. The fountain is in the Southwest corner of the backyard. . The fountain is 4 feet tall and surrounded by a fence and is inaccessible to residents. Both backyard gates are operational. No obstacles or hazards observed in the backyard. No deficiencies observed during the visit. 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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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