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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006238
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:38:06 PM

Document Has Been Signed on 10/28/2024 02:38 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CAMINO HILLS CARE HOME 1FACILITY NUMBER:
306006238
ADMINISTRATOR/
DIRECTOR:		ANG, MERCEDITAFACILITY TYPE:
740
ADDRESS:2927 BONANZATELEPHONE:
(949) 369-8390
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Mercy AngTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on deficiency cited on 09/30/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Deficiency cited under Title 22 Regulation 87303(e) pertaining to Maintenance and Operation, Water Temperature has been cleared. During the visit, LPA tested water temperature to be between 109.4 and 113.9 degrees F. Licensee has complied with the POC.






Licensee has been advised to maintain compliance in all items previously cited.




Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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