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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804404
Report Date: 11/21/2022
Date Signed: 11/21/2022 04:56:39 PM


Document Has Been Signed on 11/21/2022 04:56 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: 0DATE:
11/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Amalia Pelina, LicenseeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced visit regarding facility closure at the current location. LPA met with Amalia Pelina, Licensee to discuss the purpose of the visit.

During today's visit, LPA verified that this facility location is no longer occupied by residents. Licensee has requested facility closure and LPA has verified the relocation of residents to their new facilities. Licensee has surrendered the license for facility number 370804404 to Community Care Licensing and the facility will be closed effective 11/21/22.

An exit interview was conducted with Amalia Pelina, Licensee, and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) were provided to the Licensee, and the signature on this form acknowledges receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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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