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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850051
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:36:27 PM

Document Has Been Signed on 10/25/2024 04:36 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA DEL MAR SENIOR CARE LLCFACILITY NUMBER:
405850051
ADMINISTRATOR/
DIRECTOR:		DANIEL SEGUNDOFACILITY TYPE:
740
ADDRESS:1721 MENTONE AVETELEPHONE:
(805) 668-2090
CITY:GROVER BEACHSTATE: CAZIP CODE:
93433
CAPACITY: 6CENSUS: 0DATE:
10/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Daniel SegundoTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) De Leon conducted a case management closure visit to the facility above.
LPA met with Administrator Daniel Segundo and explained the purpose of the visit.

LPA did a walk thorough of the home. The home is empty with no residents or staff at the facility. The last resident relocated on 09/16/2024.

The current home is remodeled and listed for sale.

The closure date of 10/25/2024 if the official date no longer in business.

Administrator surrendered license to LPA on visit.

All other requirements were met.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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