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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005937
Report Date: 06/01/2021
Date Signed: 06/01/2021 05:09:57 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'S HAVEN IIIFACILITY NUMBER:
306005937
ADMINISTRATOR:MANALO, DIANNAFACILITY TYPE:
740
ADDRESS:29825 ANDREA WAYTELEPHONE:
(949) 481-2444
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 4DATE:
06/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Diana ManaloTIME COMPLETED:
05:31 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the second pre-licensing inspection. LPA was greeted and granted entry by applicant Diana Manalo. LPA observed the window screen missing in private bathroom number 2 has been replaced. LPA observed heating/AC unit has been repaired and no water is leaking from the AC/Heating unit. Both items identified on the previous pre-licensing visit (4/27/2021) have been corrected. LPA Alejandre explained the process of this application and also about post licensing visit once the facility is licensed. Component III was waived during the visit due to applicant is a current licensee for two licensed RCFE facilities and in compliance status, supervisor approved. Facility meets Title 22 requirements. Facility is ready to be licensed. An exit interview was conducted and a copy of this report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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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