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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800394
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:09:32 PM

Document Has Been Signed on 05/07/2024 04:09 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COVENANT LIVING AT MOUNT MIGUELFACILITY NUMBER:
370800394
ADMINISTRATOR/
DIRECTOR:		RICHARD MILLERFACILITY TYPE:
741
ADDRESS:325 KEMPTON STREETTELEPHONE:
(619) 479-4790
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 435CENSUS: 351DATE:
05/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Janette Getgen, Administrative AssistantTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit. LPA was greeted at the front door by Janette Getgen, Administrative Assistant and was granted facility entry. The purpose of the visit was to gather resident information.

During today’s visit the LPA received the information regarding the resident date of move in and what part of the facility the resident lives.

There were no deficiencies during todays visit.

An exit interview was conducted and a copy of this report along with the licensee rights (LIC 9058 01/16) was provided to Janette Getgen, Administrative Assistant.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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