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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600661
Report Date: 11/15/2023
Date Signed: 11/16/2023 06:14:21 AM


Document Has Been Signed on 11/16/2023 06:14 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:CALIFORNIA HOME FOR SENIORSFACILITY NUMBER:
374600661
ADMINISTRATOR:GLORIA S. QUILLOPEFACILITY TYPE:
740
ADDRESS:1061 E. BRADLEY AVENUETELEPHONE:
(619) 448-2870
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:15CENSUS: 12DATE:
11/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Caregiver Priscilla DizonTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted a case management visit to amend a report that was delivered September 24, 2023. LPA Correia gained access to the facility and met with Lead Caregiver Priscilla Dizon and explained the purpose of the Case Management visit.

During today's visit LPA amended the September 24, 2023 report and obtained signatures from Caregiver Dizon. A copy of this report and Licensee's Rights (9058 01/16) will be provided to Caregiver Dizon and an exit interview was conducted. Caregiver's signature below confirms acknowledging receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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