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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105063
Report Date: 07/14/2021
Date Signed: 07/14/2021 11:01:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:BORREGO SPRINGS YOUTH AND SENIORS CENTER, INC.FACILITY NUMBER:
376105063
ADMINISTRATOR:TERESA WESTFACILITY TYPE:
830
ADDRESS:580 CIRCLE J DRIVETELEPHONE:
(760) 767-3658
CITY:BORREGO SPRINGSSTATE: CAZIP CODE:
92004
CAPACITY:4CENSUS: 0DATE:
07/14/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Teresa WestTIME COMPLETED:
10:45 AM
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On 07/14/2021 at 10:16AM, Licensing Program Analyst (LPA) Samantha Salunga met with Teresa West (Applicant). This meeting was completed via video conferencing (Zoom). The purpose of today's meeting is to review LIC184C together and clarify anything that Applicant had questions on.

LPA reviewed entire application and observed that the following areas needed updating/correcting: application, LIC401, LIC500, LIC610, LIC999, job descriptions, director's packet, in-service training plan, employee hand book, parent handbook, admission agreement, incidental medical services, daily schedule, list of furniture and verification of address on property tax bill. LPA discussed all areas in detail with Applicant and she confirmed she will submit all discussed corrections to LPA no later than 08/09/2021.

A copy of this report was reviewed and will be e-mailed to Applicant. LPA advised that a response to the email confirming receipt is to be received within twenty-four hours. This will act as her signature on today’s report.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Samantha SalungaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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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