<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005872
Report Date: 03/30/2022
Date Signed: 04/01/2022 09:38:49 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/01/2022 09:38 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:PIERPONT MANORFACILITY NUMBER:
306005872
ADMINISTRATOR:MCKEEVER, MARIAFACILITY TYPE:
740
ADDRESS:598 PIERPONT DRTELEPHONE:
(562) 207-7216
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 0DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:TIME COMPLETED:
02:22 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz arrived to facility and observed a Danger sign indicating "This building is deemed unsafe for human occupancy under section 110.1.1 of the California fire code." During today's visit, LPA Rosie Quiroz called and spoke to assigned Costa Mesa Combination inspector who verified property remains vacant at this time.

LPA Rosie Quiroz walked exterior of premises. No one present in the home as evidenced by LPA Rosie Quiroz did not observe anyone inside the facility during window observations. There were visible wheel chairs, walkers or any other medical devices present during today's exterior observations.

On 3/18/2021, The Department was notified of a fire at facility. There were no residents or staff during time of fire.

Facility is currently deemed uninhabitable per local fire department and city inspectors. During today's visit, LPA Rosie Quiroz confirmed that facility remains vacant.

Administrator not present to sign today's report. Copy of report will certified mailed to Licensee.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1