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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804865
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:38:37 PM


Document Has Been Signed on 07/14/2023 03:38 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:CARROLLS RESIDENTIAL CAREFACILITY NUMBER:
370804865
ADMINISTRATOR:BRYAN MEYERSFACILITY TYPE:
740
ADDRESS:655 S MOLLISONTELEPHONE:
(619) 444-3181
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:144CENSUS: 123DATE:
07/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Bryan Meyers TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Other visit to perform a welfare check on residents in care. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Bryan Meyers.

During today's visit, LPA briefly toured the facility and performed a welfare check on residents in care, finding no immediate safety concerns. LPA reviewed a selection of five (5) resident records and five (5) staff records. LPA also interviewed staff.

No deficiencies were cited during today's visit. However, LPA delivered one Technical Violation (refer to the LIC9102-TV) regarding the facility's Theft and Loss policy/procedures.

An exit interview was conducted with Meyers, to whom a copy of this report, the LIC9102-TV, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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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