<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006492
Report Date: 07/26/2024
Date Signed: 07/26/2024 12:23:29 PM


Document Has Been Signed on 07/26/2024 12:23 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: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:
07/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Eleazar Cuyson, Administrator
Maricel Nepomuceno, licensee		TIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility to follow-up on the initial pre-licensing visit held on July 19, 2024. LPA was greeted and granted entry by Maricel Nepomuceno, licensee and Eleazar Cuyson, administrator.

LPA was able to verify that the physician report for resident R1 had been adequately signed by the resident's primary care physician. Water temperature was also measured to be 120F.

Based on these updated observations, LPA was able to confirm that the applicant is ready for licensing. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1