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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374845455
Report Date: 09/27/2019
Date Signed: 09/27/2019 01:47:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:NCCS WEST MISSION CDCFACILITY NUMBER:
374845455
ADMINISTRATOR:MOORE, ESTRELLITAFACILITY TYPE:
850
ADDRESS:715 W. MISSION AVE SUITE ATELEPHONE:
(760) 471-5483
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:60CENSUS: 36DATE:
09/27/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Doris Roldan, DirectorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Mariah McCarty made an unannounced visit to the facility, and met with Doris Roldan, Director. A case management visit was conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on September 16, 2019. It indicated a child was left alone unsupervised outside on September 12, 2019.

Facility records were reviewed, and staff were interviewed. Based on the information gathered, facility staff did not meet the Responsibility for Providing Care and Supervision. See complaint received on 9/20/19 for further details.

A NOTICE OF SITE VISIT WAS ISSUED AND LPA VERIFIED THAT IT WAS POSTED IN A PROMINENT LOCATION AT THE FACILITY BEFORE LEAVING. THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS



An exit interview was conducted, and a copy of this report was provided to Doris Roldan, Director.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Mariah McCartyTELEPHONE: (951) 255-4093
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019
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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