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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808350
Report Date: 05/06/2024
Date Signed: 05/06/2024 08:45:04 PM

Document Has Been Signed on 05/06/2024 08:45 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BAUM ADULT RESIDENTIAL FACILITY #2FACILITY NUMBER:
370808350
ADMINISTRATOR/
DIRECTOR:		BAUM, CHERYLFACILITY TYPE:
735
ADDRESS:9680 PETITE LANETELEPHONE:
(619) 561-7524
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 5DATE:
05/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Licensee Cheryl BaumTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Debbie Correia conducted case management visit to obtain Licensee Baum's signature on an amended a report. LPA identified herself and stated the purpose of the visit.

LPA informed the Licensee Baum of the reason for the amended report and obtained signatures.

An exit interview was conducted with Licensee Baum. A copy of this report along with Licensee Rights (LIC9058 01/2016) will be provided to Licensee Baum. Signature below response confirms receipt of the documents.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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