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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804359
Report Date: 04/20/2023
Date Signed: 04/20/2023 12:13:47 PM


Document Has Been Signed on 04/20/2023 12:13 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:KASITZ KASTLEFACILITY NUMBER:
370804359
ADMINISTRATOR:DARLENE KASITZFACILITY TYPE:
740
ADDRESS:1417 TAVERN ROADTELEPHONE:
(619) 445-3887
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY:12CENSUS: 4DATE:
04/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Administrator Agnieszka NortonTIME COMPLETED:
12:29 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Ramon Serrano and Debbie Correia conducted an announced Case Management visit. LPAs were granted entry into the facility by Administrator Agnieszka Norton, identified themselves and stated the purpose of the visit.

LPAs provided consultation on Guardian, conducted a review on PIN 23-05-CCLD, and advised Norton to create a Guardian account, as well as register to receive CCL Provider Notification Information (PINS). Administrator Norton was also given the CCL RO email to use in lieu of the fax number.

An exit interview was conducted, and a copy of this report and a copy of the Appeal Right (LIC 9058) was provided to Administrator Agnieszka Norton, whose signature below confirms.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
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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