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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006050
Report Date: 10/27/2021
Date Signed: 10/27/2021 11:44:01 AM

Document Has Been Signed on 10/27/2021 11:44 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:MIA RESIDENCEFACILITY NUMBER:
306006050
ADMINISTRATOR:ADOLFO, JEDFACILITY TYPE:
740
ADDRESS:25475 ADRIANA STTELEPHONE:
(949) 529-4130
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
10/27/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Giannina AdolfoTIME COMPLETED:
11:55 AM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Jerome Haley made an announced visit to conduct the second pre-licensing visit. LPAs were greeted and granted entry by staff. LPAs explained the reason for the visit. LPAs observed all staff were wearing masks. Applicant Giannina Adolfo toured the facility with the LPAs. LPAs observed the see something say something poster (pub 475) is posted in the entrance of the facility and is the correct size. LPAs observed the fireplace in the bedroom adjacent to the living is now screened. The new fireplace screen is made of metal and covers the entire fireplace. Applicant has corrected the deficiencies listed in the previous report (see LIC 809 dated 10/20/21). The facility is ready to be licensed. Applicant was informed today that the final approval will be processed by the Central Applications Unit (CAU) supervisor in Sacramento. Component III was waived during the visit due to applicant is a current licensee for a licensed facility and in compliance status, supervisor approved. LPA informed applicant about the post licensing visit once the facility is licensed. Applicant stated she understood. An exit interview was conducted and a copy of this report, LIC809, was explained and provided to applicant.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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