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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004436
Report Date: 07/26/2021
Date Signed: 07/26/2021 10:22:58 AM

Document Has Been Signed on 07/26/2021 10:22 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:MAPLE MANORFACILITY NUMBER:
372004436
ADMINISTRATOR:SNEZANA DJUKICFACILITY TYPE:
740
ADDRESS:1744 SO. MAPLETELEPHONE:
(760) 743-0632
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 31CENSUS: 13DATE:
07/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Djukic SnezanaTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Eva Torres conducted a case management visit to amend a report that was created on 05/05/20. LPA Torres met with Administrator, Djukic Snezana, and informed them of the purpose of the visit. During the visit, LPA issued the amended report. An exit interview was conducted with the administrator, and the Licensee’s Rights (LIC9058 01/16) along with a copy of this report was emailed to them. A reply email or return receipt from the administrator will confirm receipt of documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2021
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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