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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370802857
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:54:51 AM

Document Has Been Signed on 01/20/2023 11:54 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CARROLL'S COMMUNITY CAREFACILITY NUMBER:
370802857
ADMINISTRATOR:ROGELIO HERNANDEZFACILITY TYPE:
735
ADDRESS:523 EMERALD AVENUETELEPHONE:
(619) 442-8893
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 70CENSUS: 68DATE:
01/20/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Administrator, Rogelio HernandezTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton made an unannounced visit to the facility to conduct a Plan of Correction (POC) visit to verify the corrections of deficiencies cited on December 5, 2022. An extension was given until January 20, 2023. LPA was greeted by Administrator, Rogelio Hernandez and granted entry after identifying herself. LPA discussed the purpose of the visit.

During today's visit, LPA toured the facility and observed cited areas. All areas of the type B deficiency cited on December 5, 2022 have been corrected.

This report was discussed with Administrator, Hernandez. A copy of this report along with Licensee/Appeal Rights, was provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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