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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423838
Report Date: 08/23/2022
Date Signed: 08/23/2022 01:41:54 PM

Document Has Been Signed on 08/23/2022 01:41 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GYPSUM CREEK HOME #2FACILITY NUMBER:
336423838
ADMINISTRATOR:LILIAN TOLENTINOFACILITY TYPE:
735
ADDRESS:14572 SLEEPY CREEK DRIVETELEPHONE:
(951) 220-7499
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 5DATE:
08/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Carlito Tan, LicenseeTIME COMPLETED:
02:00 PM
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Licensing Program Analyst is conducting this case management for the purpose of a health and safety evaluation in response to the incident reporting the death of C1 on 08/17/2022. LPA collected records for C1. LPA conducted a tour of the facility and grounds, assessing the physical plant, staffing, food supply, and general care of clients. Clients are present during this tour engaged in various activities of choice. There are four caregivers and five clients in the home at the time of this visit. Sufficient staff are present at the facility to provide care. LPA observed three (3) days supply of perishable and seven days (7) supply of non-perishable food. No imminent health and/or safety concerns identified at the time of this visit

This report was reviewed with and a copy was provided to Carlito Tan during the exit discussion.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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