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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808372
Report Date: 08/09/2022
Date Signed: 08/10/2022 09:17:33 AM

Document Has Been Signed on 08/10/2022 09:17 AM - 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:UNYEWAY, INC.-ADULT DEVELOPMENT CENTERFACILITY NUMBER:
370808372
ADMINISTRATOR:MARGIE SWAFFORDFACILITY TYPE:
775
ADDRESS:11440 RIVERSIDE DR, A-D & I-KTELEPHONE:
(619) 562-6330
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 224CENSUS: 130DATE:
08/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Program Director, Jody DyeTIME COMPLETED:
04:23 PM
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Licensing Program Analyst (LPA) Debbie Corriea conducted an unannounced Case Management visit. LPA was greeted at the front door by Program Director (PD) Jody Dye, identified herself, was granted entry and discussed the purpose of her visit.

The visit was initiated due to a self reported incident involving client #1 (C1) and staff #1 (S1). The PD self-reported this incident by submitting form LIC 624 – Unusual Incident/Injury Report to Community Care Licensing (CCL) and a SOC 341 for mandated reporting, which was received in our office on August 9, 2022.

During today’s visit, LPA conducted staff interviews and obtained and requested resident and staff records. No deficiencies were issued during today's visit.

An exit interview was conducted with PD Dye and a copy of this report, Confidential Names (LIC 811) as well as Licensee Rights (LIC 9058 01/16) was provided to PD Dye and signature below confirms receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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