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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005937
Report Date: 07/27/2021
Date Signed: 07/27/2021 01:39:31 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: DATE:
07/27/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dianna ManaloTIME COMPLETED:
01:50 PM
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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 Administrator Diana Manalo. Administrator's certificate expires 11/15/2021. LPA and Administrator toured the facility. Facility has 5 bedrooms and 2 bathrooms. All the resident bedrooms had the required furnishings and were clean and organized. The garage is used for storage and kept locked. Smoke detectors were tested and are operational. Carbon monoxide detector was tested and is operational. Both bathrooms are clean and operational. The kitchen was clean and LPA observed the medications are kept in a ktichen cabinet that is kept locked. LPA inspected the first aid kit and it contained all the required elements. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. LPA did not observe any obstacles or hazards in the facility. LPA toured the backyard of the facility. No bodies of water observed. Both backyard exit gates are operational, latched and secured. LPA observed a patio table with chairs and an umbrella. LPA did not observe any obstacles or hazards in the backyard. Facility is pending mitigation plan approval. No deficiencies are being cited. LPA conducted an exit interview with the Administrator and a copy of the report was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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