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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005697
Report Date: 09/20/2021
Date Signed: 09/20/2021 01:50:07 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 SOL IV RSLFACILITY NUMBER:
306005697
ADMINISTRATOR:MAYORGA, JONATHANFACILITY TYPE:
740
ADDRESS:27041 MALLORCA LANETELEPHONE:
(949) 357-6255
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Administrator TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this facility. Via phone, LPA spoke with Administrator (AD) Jonathan "Jon" Mayorga. AD arrived in the facility shortly after. LPA stated the purpose of this visit.

The facility is a two level structure and licensed for 6 non-ambulatory of which 1 may be bedridden; and with hospice waiver for two. For this visit there were no residents in care.

For this visit, the facility was observed to be under renovation. AD Jon Mayorga walked through the Coronavirus 2019 (COVID 19) mitigation plan of the facility. AD will implement the facility infection prevention and control policies and procedures once they admit residents in this facility.

For this visit, no deficiency was observed, and no citation was issued.

LPA conducted an exit interview with AD Jon Mayorga; and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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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