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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005889
Report Date: 10/14/2022
Date Signed: 10/14/2022 11:36:51 AM


Document Has Been Signed on 10/14/2022 11:36 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 HAVEN IIFACILITY NUMBER:
306005889
ADMINISTRATOR:MANALO, DIANNAFACILITY TYPE:
740
ADDRESS:29251 VIA SAN SEBASTIANTELEPHONE:
(949) 258-2063
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 4DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Dianna ManaloTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Administrator Dianna Manalo. Administrator's certificate for Dianna Manalo expires 11/15/2023. Facility is a single story home with 5 bedrooms and 2 bathrooms, kitchen, dining room, family room and a passage way room (passage way room has a filing cabinet and a fold up bed) with 3 doors (one door leads to the garage, one is to the outside front porch and one to the hallway) leading to the two car garage. LPA and Administrator toured the facility. LPA observed the garage is kept locked and used for storage. LPA observed all resident bedrooms had the required furnishings. All the bedrooms had enough space to accommodate each resident and their belongings. LPA inspected both bathrooms. Both bathrooms are clean and operational. LPA observed both showers had anti-skid mats and secure grab bars.. Hot water in both bathrooms measured 108.6 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed the fire extinguisher in the kitchen is fully charged. LPA observed the gas stove top is operational. LPA observed there is a 2 day perishable food supply and a 7 day non-perishable food supply on hand. The smoke/carbon monoxide detectors tested operational. LPA and the Administrator toured the backyard. No bodies of water observed. LPA observed a table under the awning with chairs for residents to sit outside. No obstacles or hazards observed in the backyard. The exit gate is operational. The first aid kit has all the required elements. No obstacles or hazards observed during the visit. LPA consulted with the Administrator concerning continued Covid-19 mitigation procedures, reporting requirements and medication administration and storage. 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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