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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880867
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:28:43 AM

Document Has Been Signed on 08/31/2023 11:28 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,
, CA
FACILITY NAME:JANELLE LN ARFFACILITY NUMBER:
331880867
ADMINISTRATOR:DOST, HAROONFACILITY TYPE:
735
ADDRESS:31058 JANELLE LNTELEPHONE:
(858) 733-1876
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 2DATE:
08/31/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Nazifa Azizi, CaregiverTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Javina George made an unannounced collateral visit to conduct interviews for an unrelated matter to the facility.

The purpose of the visit was to conduct an interview with Resident #1 (R1) in regards to an open complaint not related/associated to this facility.

LPA was greeted and granted entry by Caregiver Nazifa, where LPA explained the purpose of her visit.

No heath and safety concerns were observed at the time of LPAs visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver Nazifa Azizi.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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