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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808112
Report Date: 12/13/2021
Date Signed: 12/13/2021 02:00:37 PM

Document Has Been Signed on 12/13/2021 02:00 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:FANCOR GUEST HOMEFACILITY NUMBER:
370808112
ADMINISTRATOR:HUERTAS, FANNIEFACILITY TYPE:
735
ADDRESS:631-651 TAFT AVENUETELEPHONE:
(619) 588-1761
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 44CENSUS: 42DATE:
12/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Assistant Administrator, Myra PalmerTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced case-management visit. LPA met with Assistant Administrator, Myra Palmer, and discussed the purpose of the visit.

This visit was initiated due to the death of Client #1 (C1). Ms. Palmer was provided with Confidential Names Form, in order to identify C1. It was reported to Community Care Licensing (CCL), that C1 passed away on 12/10/21.

During today's visit, LPA toured the facility, interviewed Ms. Palmer, and obtained copies of C1's records. A copy of C1's death certificate was requested to be provided by Administrator, Cyralynn Mabalot, once received. No immediate health and/or safety concerns were observed during the visit.

No deficiencies were cited during today's visit. An exit interview was conducted with Ms. Palmer, and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to the Administrator via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Lizzette Tellez
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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