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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372000400
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:47:20 PM


Document Has Been Signed on 03/28/2022 04:47 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:NAZARETH HOUSEFACILITY NUMBER:
372000400
ADMINISTRATOR:PETROSYAN, MILENAFACILITY TYPE:
740
ADDRESS:6333 RANCHO MISSION ROADTELEPHONE:
(619) 563-0480
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:145CENSUS: 92DATE:
03/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Milena PetrosyanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on a Death Report received by the Regional Office on 03/25/2022. LPA was greeted by, identified herself to, and explained the purpose of the visit to Executive Director Milena Petrosyan.

During the visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed the Executive Director and staff. No immediate health or safety concerns were observed during the visit.

No deficiencies were observed or cited on this date. An exit interview was conducted with Executive Director Milena Petrosyan, to whom a copy of this report and the Licensee Rights (LIC 9058 01/16) were provided via email.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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