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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006492
Report Date: 06/18/2024
Date Signed: 06/24/2024 09:58:40 AM


Document Has Been Signed on 06/24/2024 09:58 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:HILLS OF MALLORCA, THEFACILITY NUMBER:
306006492
ADMINISTRATOR:CUYSON, ELEAZARFACILITY TYPE:
740
ADDRESS:27041 MALLORCA LANETELEPHONE:
(714) 430-7672
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
06/18/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maricel Nepomuceno (Licensee), Eleazar Cuyson (Administrator)TIME COMPLETED:
02:30 PM
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COMP II by CAB successfully completed
Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census : 5
Method: Telephone call with CAB
COMP II Participants: Maricel Nepomuceno (Licensee), Eleazar Cuyson (Administrator), & Tammy
Edwards, (Analyst).

Licensee & administrator participated in COMP II via Telephone call with CAB Analyst. Identification
of licensee/ administrator was verified by confirming driver’s license numbers. During COMP II,
licensee/ administrator confirmed the understanding of Title 22. Component II was successfully
completed. Licensee/administrator were advised to email signed LIC 809 with copy of photo ID to
CAB.

During COMP II, CAB analyst confirmed licensee's/administrator’s understanding of following
areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) -65-7817
LICENSING EVALUATOR NAME: Tammy EdwardsTELEPHONE: 916-651-9141
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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