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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370802865
Report Date: 11/03/2021
Date Signed: 11/03/2021 04:05:49 PM

Document Has Been Signed on 11/03/2021 04:05 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:ORLANDO GUEST HOMEFACILITY NUMBER:
370802865
ADMINISTRATOR:CYRALYNN MABALOTFACILITY TYPE:
735
ADDRESS:297 -299 ORLANDOTELEPHONE:
(619) 444-9411
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 34CENSUS: 34DATE:
11/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:24 PM
MET WITH:Fe MartinezTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Kennedy conducted a case management visit regarding an incident report that was received by CCL on 11-1-21 for Client 1 (C1). LPA identified herself and discussed the purpose of the visit with Fe Martinez, Assistant Administrator. The purpose of this visit was to follow up on the incident reports regarding the AWOL of Client 1. (See LIC 811 Confidential Names)

Incident report dated 11-1-21 regarding the AWOL of C1 on 10-30-21. The client does not have a history of AWOL. The client is able to leave the facility unassisted. Facility has an AWOL plan in place. The police were called and made aware of incident. C1 has not returned to the facility as of the time of the visit.

No deficiencies cited today during visit.

An exit interview was conducted with Fe Martinez, Assistant Administrator A copy of this report was provided to the administrator via email. An electronic response confirms the documents were received. Licensee Rights (LIC9058 01/2016) were left at the facility.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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