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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004630
Report Date: 10/12/2022
Date Signed: 10/12/2022 11:40:12 AM


Document Has Been Signed on 10/12/2022 11:40 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,
, CA



FACILITY NAME:COUNTRY CLUB GUEST HOMEFACILITY NUMBER:
372004630
ADMINISTRATOR:RAMIREZ, JULIEFACILITY TYPE:
740
ADDRESS:25533 RUA MICHELLETELEPHONE:
(760) 747-0957
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:30CENSUS: 25DATE:
10/12/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Julita RamirezTIME COMPLETED:
11:58 AM
NARRATIVE
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Licensing Program Analyst (LPA), Ramon Serrano, conducted an unannounced collateral visit as a follow-up for an unrelated complaint investigation for another facility. LPA was allowed entry by Clara Aguas and discussed the purpose of the visit with Licensee Julita Ramirez.

During the visit, LPA conducted interviews with staff members.

An exit interview was conducted with Julita Ramirez and copy of this report along with Licensee Rights (LIC 9098, 01/16) was provided to Julita Ramirez whose signature below verifies receipt of these rights.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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