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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306006537
Report Date:
12/17/2024
Date Signed:
12/17/2024 07:11:33 AM
Document Has Been Signed on
12/17/2024 07:11 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:
MERCY MANOR CORP
FACILITY NUMBER:
306006537
ADMINISTRATOR/
DIRECTOR:
GUILING, AISA
FACILITY TYPE:
734
ADDRESS:
1702 LA COLINA DR
TELEPHONE:
(909) 841-6315
CITY:
SANTA ANA
STATE:
CA
ZIP CODE:
92705
CAPACITY:
5
CENSUS:
DATE:
12/17/2024
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:
Jessica Garcia
TIME VISIT/
INSPECTION COMPLETED:
07:30 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a follow up pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Licensee Jessica Garcia. An initial application to operate an Adult Residential Facility for Persons with Special Health Needs was received by Community Care Licensing on 03/20/2024 for a capacity of five bedridden clients.
LPA toured the facility and observed the following:
Exit gate is operational during today's visit.
Facility is ready to be licensed.
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:
12/17/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/17/2024
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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