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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804165
Report Date: 10/30/2020
Date Signed: 10/30/2020 04:21:51 PM

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:GOOD SAMARITAN BOARD AND CARE FACILITYFACILITY NUMBER:
370804165
ADMINISTRATOR:FAYE MAYOFACILITY TYPE:
740
ADDRESS:6255 MCHANEY COURTTELEPHONE:
(619) 267-2445
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 5DATE:
10/30/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Angelita Sanchez, LicenseeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Daniel Pena conducted a Case Management visit to follow up on a pre-licensing Inspection virtual visit conducted on 10/08/2020. LPA Pena met with Administrator Sanchez, via FaceTime, due to Covid-19 and informed her of the purpose of the visit.

During today’s virtual visit, LPA reviewed the Licensee's modified facility sketch. Subsequent to a virtual tour of the facility, LPA confirmed the floor plan and facility sketch are consistent with the Fire Clearance which was approved on 09/20/2020.

CCLD has completed the virtual pre-licensing inspection and LPA provided the Licensee with the Comp III Orientation. CCLD management was informed of the findings of the inspection. Final review and approval is pending with the Application Bureau.

An exit interview was conducted with Administrator Sanchez and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to the Administrator via email. A return email from the administrator confirms receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
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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