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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006050
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:57:49 PM

Document Has Been Signed on 10/23/2024 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MIA RESIDENCEFACILITY NUMBER:
306006050
ADMINISTRATOR/
DIRECTOR:		ADOLFO, JEDFACILITY TYPE:
740
ADDRESS:25475 ADRIANA STTELEPHONE:
(949) 305-5259
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Giannina AdolfoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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An informal conference was conducted on this date in the Orange County Adult and Senior Care Regional Office. The purpose of this informal conference was to discuss concerns regarding the operation of the facility.

Present during this meeting were Regional Manager (RM) Marina Stanic, Licensing Program Manager (LPM) Lourdes Montoya, Licensing Program Analysts (LPAs) Edward Kim and Eboni Bentley, and Licensee Giannina Marie Adolfo.

During the informal conference, the following items were discussed:
  • The Eviction Procedure.
  • The staffing.
  • Medication.


The following was agreed to: the Licensee entered into a 6 months compliance plan where the department will conduct additional visits to the facility to verify compliance with regulation and offer assistance.

An exit interview was conducted and a copy of this report was discussed with and provided to Licensee Giannina Marie Adolfo.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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