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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005823
Report Date:
06/13/2022
Date Signed:
06/13/2022 12:22:29 PM
Document Has Been Signed on
06/13/2022 12:22 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:
TRUE REFUGE
FACILITY NUMBER:
306005823
ADMINISTRATOR:
RILLERA, MICHAEL P.
FACILITY TYPE:
735
ADDRESS:
4331 FIRESIDE CIR.
TELEPHONE:
(949) 653-7562
CITY:
IRVINE
STATE:
CA
ZIP CODE:
92604
CAPACITY:
5
CENSUS:
0
DATE:
06/13/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:24 AM
MET WITH:
Michael Rillera
TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Administrator Michael Rillera and explained the reason for the visit.
LPA Mendivil toured the facility. There are no clients residing in the facility. At this time Administrator intends to accept first client on 07/01/2022.
No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Alisa Ortiz
LICENSING EVALUATOR NAME
:
Andrea Mendivil
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/13/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/13/2022
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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