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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600508
Report Date: 06/25/2024
Date Signed: 06/25/2024 05:06:13 PM

Document Has Been Signed on 06/25/2024 05:06 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:VELASCO HOME IIIFACILITY NUMBER:
374600508
ADMINISTRATOR/
DIRECTOR:		ELIZABETH VELASCOFACILITY TYPE:
735
ADDRESS:1549 GRAND TETON COURTTELEPHONE:
(619) 691-0761
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 5DATE:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Caregiver Rony PinoTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself, and discussed the purpose of the visit with Caregiver Rony Pino.

During today’s visit, LPA toured the facility, reviewed staff and client records, and interviewed staff and clients. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection.

An exit interview was conducted with Pino. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to the Licensee during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
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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