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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
370808350
Report Date:
10/24/2023
Date Signed:
10/28/2023 01:17:06 PM
Document Has Been Signed on
10/28/2023 01:17 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 #2
FACILITY NUMBER:
370808350
ADMINISTRATOR:
BAUM, CHERYL
FACILITY TYPE:
735
ADDRESS:
9680 PETITE LANE
TELEPHONE:
(619) 561-7524
CITY:
LAKESIDE
STATE:
CA
ZIP CODE:
92040
CAPACITY:
6
CENSUS:
DATE:
10/24/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Attempted Visit
TIME COMPLETED:
02:37 PM
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SUPERVISORS NAME
:
Simon Jacob
LICENSING EVALUATOR NAME
:
Debbie Correia
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
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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