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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804404
Report Date: 08/30/2022
Date Signed: 08/30/2022 12:38:57 PM


Document Has Been Signed on 08/30/2022 12:38 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:SILVERCREST GUEST HOMEFACILITY NUMBER:
370804404
ADMINISTRATOR:PELINA, AMALIAFACILITY TYPE:
740
ADDRESS:960 GROSSMONT AVENUETELEPHONE:
(619) 442-3957
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:15CENSUS: 10DATE:
08/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Amalia Pelina, Administrator TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted a case management visit to amend a Complaint Report (LIC 9099-C) that was generated and left at the facility on 8/26/22. LPA was granted entry into the facility by Amalia Pelina, Administrator and discussed the purpose of the visit.

An exit interview was conducted with Amalia Pelina, Administrator and a copy of this report, amended LIC 9099-C, and Licensee Appeal Rights (LIC 9058) have been provided to Amalia Pelina, Administrator.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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