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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005697
Report Date: 11/02/2022
Date Signed: 11/02/2022 02:18:14 PM


Document Has Been Signed on 11/02/2022 02:18 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: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: 6DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Jonathan MayorgaTIME COMPLETED:
02:40 PM
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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 Jonathan Mayorga. LPA and Administrator toured the facility. The facility is a two story home with 6 bedrooms, 3 bathrooms, office, living room with a screened fireplace, kitchen, dining room, living room and a two car garage. The second story is for staff only and includes 2 bedrooms, the office and one bathroom. LPA observed there is no PUB 475 poster in the main entrance of the facility. LPA observed all the resident rooms were clean and organized. LPA observed the medication is kept locked in the hall closet. .LPA observed both downstairs bathrooms were clean and operational. Smoke detectors/carbon monoxide detectors tested operational. LPA observed a 2 day perishable food supply in the kitchen and a 7 day non-perishable food supply in the garage. The garage is kept locked and used for storage. LPA observed the ktichen is clean and organized. LPA and Administrator toured the backyard. LPA observed a table with an umbrella to sit outside. No bodies of water observed. LPA observed a ladder, 3 wheel chairs and roofing tile next to the garage by the exit gate. Both exit gates are operational. LPA and Administrator toured the second story for the facility. The second story is for staff only. No deficiencies observed on the second floor. LPA observed both fire extinguishers are fully charged. LPA inspected the first aid kit and it had all the required elements. LPA consulted with the Administrator concerning continued Covid-19 mitigation procedures and reporting requirements. 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: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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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