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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800394
Report Date: 06/17/2022
Date Signed: 06/17/2022 04:22:39 PM

Document Has Been Signed on 06/17/2022 04:22 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COVENANT LIVING AT MOUNT MIGUELFACILITY NUMBER:
370800394
ADMINISTRATOR:RICHARD MILLERFACILITY TYPE:
741
ADDRESS:325 KEMPTON STREETTELEPHONE:
(619) 479-4790
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 434CENSUS: 430DATE:
06/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Brian McBee, Executive DirectorTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an announced Case Management visit. LPA was greeted at the front door by Brian McBee, Executive Director, and was granted facility entry. The purpose of the visit was to discuss the licensee’s request for a change in capacity from fourteen (14) to fifteen (15) ambulatory residents.

LPA met with Brian McBee, Executive Director and discussed the change of capacity.

The fire clearance dated 03/09/2022 shows a clearance granted for 15 ambulatory and 420 non ambulatory.

During today’s visit the LPA conducted a tour of the facility accompanied by Brian McBee, Executive Director. LPA found the physical plant is consistent with the submitted facility sketch/floor plan.

Based on today’s inspection, living accommodations and grounds have been found to be in compliance, meeting Title 22 regulations for an increase in capacity.

The completed change of capacity request will be forwarded to management for final review and approval. Approval notification to licensee will be made by Community Care Licensing and a new license will be mailed to the licensee pending approval.

An exit interview was conducted and a copy of this report along with the licensee rights (LIC 9058 01/16) was provided to Brian McBee, Executive Director whose signature below confirms receipt.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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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