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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808112
Report Date: 05/22/2023
Date Signed: 05/22/2023 01:29:14 PM

Document Has Been Signed on 05/22/2023 01:29 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: 44DATE:
05/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Myra Palmer, AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced case management visit to follow-up on an incident discovered during a complaint investigation visit. LPA introduced herself, was granted entry into the facility, and met with Myra Palmer, Administrator, to whom she disclosed the purpose of the visit.

While conducting a visit to the facility, LPA was informed that a client in care (C1) [an LIC 811 Confidential Names List that identifies the client was provided] was absent from the facility without leave. LPA was informed that C1 left the facility on May 15, 2023 and has not returned. During today's visit, LPA conducted a health and safety check, interviewed staff, and obtained copies of facility records.

LPA was informed that El Cajon Police Department, C1’s responsible party, and C1’s physician were notified of C1’s absence, all of which were in accordance with C1’s absentee plan. No deficiencies were cited during the visit.

An exit interview was conducted with Myra Palmer, and a copy of this report and Licensee Appeal Rights (LIC 9058) were provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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