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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
374600027
Report Date:
06/20/2024
Date Signed:
06/20/2024 09:33:13 AM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
06/20/2024 09:33 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
SAN DIEGO RO
,
7575 METROPOLITAN DR. #109
SAN DIEGO
,
CA
92108
FACILITY NAME:
FAMILY VALUES ADULT RESIDENTIAL FACILITY
FACILITY NUMBER:
374600027
ADMINISTRATOR/
DIRECTOR:
REGINA AGUILO UY
FACILITY TYPE:
735
ADDRESS:
8509 DALLAS STREET
TELEPHONE:
(619) 697-4685
CITY:
LA MESA
STATE:
CA
ZIP CODE:
91942
CAPACITY:
4
CENSUS:
4
DATE:
06/20/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
Regina Uy Administrator
TIME VISIT/
INSPECTION COMPLETED:
09:31 AM
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection on 3/14/24 with Regina Uy the Administrator. No deficiencies were observed or cited during today's annual inspection.
SUPERVISORS NAME
:
Simon Jacob
LICENSING EVALUATOR NAME
:
Amy Domingo
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/20/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/20/2024
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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