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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006249
Report Date: 01/24/2023
Date Signed: 07/10/2023 10:45:07 AM


Document Has Been Signed on 07/10/2023 10:45 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:OC HOME OF LAGUNA NIGUELFACILITY NUMBER:
306006249
ADMINISTRATOR:ANGELES, LOIDAFACILITY TYPE:
740
ADDRESS:23962 HILLHURST DRIVETELEPHONE:
(949) 202-8908
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: DATE:
01/24/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Loida AngelesTIME COMPLETED:
03:10 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): zero
Method: Telephone call with CAB
COMP II Participants: Loida Angeles, Applicant/administrator

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 to CAB.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
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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