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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006095
Report Date: 04/28/2022
Date Signed: 04/28/2022 11:30:04 AM


Document Has Been Signed on 04/28/2022 11:30 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:EPIC ASSISTANCE CARE HOMEFACILITY NUMBER:
306006095
ADMINISTRATOR:MESDJIAN, LIZAFACILITY TYPE:
740
ADDRESS:26751 CARRETAS DRIVETELEPHONE:
(818) 220-0282
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Simona Aziza, administratorTIME COMPLETED:
11:45 AM
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On this day, Licensing Program Analyst (LPA) conducted a scheduled follow-up visit for the purpose of completing the pre-licensing for the facility.

LPA was greeted and granted entry by caregiving staff. LPA accompanied by administrator Simona Aziza toured the facility and was able to observe that a fireplace screen has been put in place. Nightlights have also been installed in each bedroom as well as in the hallways and kitchen in order to secure nighttime circulation in the physical plant.

All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. An exit interview and a copy of the report were provided at the time of the exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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