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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808350
Report Date: 10/21/2021
Date Signed: 10/24/2021 05:46:34 PM

Document Has Been Signed on 10/24/2021 05:46 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:BAUM ADULT RESIDENTIAL FACILITY #2FACILITY NUMBER:
370808350
ADMINISTRATOR:BAUM, CHERYLFACILITY TYPE:
735
ADDRESS:9680 PETITE LANETELEPHONE:
(619) 561-7524
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:, Attempted VisitTIME COMPLETED:
05:30 PM
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LPA Correia attempted to conduct an unannounced visit to complete an annual inspection. Upon arrival, LPA called the facility to assess the facility COVID-19 status, however no one answered the facility phone. LPA proceeded to the approach the facility and ring the doorbell and knock on the front entrance however no one answered.

LPA called Licensee Cheryl Baum who informed LPA the facility staff and clients were out on an outing, and she was currently accompanying a client, from another facility at the hospital, and was not available. She met with LPA Vo last week at Baum Adult Residential Facility #1 last week and completed the Infection control annual visit and completed the review of the up to date LIC 808- COVID-19 mitigation plan. Licensee agreed to email the LIC 808 first thing in the morning,

LPA to return at a later date.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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