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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004894
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:21:48 PM

Document Has Been Signed on 05/18/2023 03:21 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:TIERRASANTA VERNANEL CARE HOMEFACILITY NUMBER:
372004894
ADMINISTRATOR:PANAO, NELLY, D.FACILITY TYPE:
740
ADDRESS:11085 ZAGALA COURTTELEPHONE:
(858) 569-1870
CITY:SAN DIEGOSTATE: CAZIP CODE:
92124
CAPACITY: 6CENSUS: 3DATE:
05/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Nelly Panao, AdministratorTIME COMPLETED:
03:15 PM
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On 5/18/2023 at about 2:45 PM, Licensing Program Analyst (LPA), Daniel Pena, conducted an unannounced Case Management visit to the facility. LPA was met at the entry by Nelly Panao, Administrator. After introducing himself, displaying his identification and explaining the purpose of the visit, LPA was allowed into the facility.

During the visit, LPA obtained copies of records and performed a brief tour. LPA did not observe any deficiencies and no citations were administered.

An exit interview was conducted with Administrator Panao, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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