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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600145
Report Date: 06/23/2020
Date Signed: 06/23/2020 05:22:01 PM

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:ALEXA'S PLAYCFACILITY NUMBER:
376600145
ADMINISTRATOR:ANDREA WILSONFACILITY TYPE:
850
ADDRESS:3685 KEARNY VILLA ROADTELEPHONE:
(858) 966-8555
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:92CENSUS: 16DATE:
06/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Arielle KingTIME COMPLETED:
05:25 PM
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On 06/23/2020 at 5:15pm, Licensing Program Analyst (LPA) Samantha Salunga conducted an case management televisit with Arielle King, Behaviorhal Specialist . Due to COVID-19 state of emergency, in person inspections are not allowed at this time. This televisit was completed via video conferencing (FaceTime). Purpose of this televisit is to follow up on a self-reported incident that was reported to CCL yesterday, 06/22/2020. Ms. King stated that Ms. Camacho, Facility Manager, has the necessary follow-up information that LPA needs regarding the UIR. Ms. King provided Nora Camacho's contact information due to her not being on site. LPA provided facility representatives several COVID-19 resources via email.

A copy of this report and NOS was reviewed and will be e-mailed to Ms. Camacho. Ms. Camacho was advised that acknowledgement of the receipt of this report is to be received within twenty-four hours.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Samantha SalungaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
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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