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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600906
Report Date: 03/01/2022
Date Signed: 03/01/2022 11:03:03 PM

Document Has Been Signed on 03/01/2022 11:03 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:WHITE, MRS. PATRICIA M.FACILITY NUMBER:
374600906
ADMINISTRATOR:PATRICIA M. WHITEFACILITY TYPE:
735
ADDRESS:12222 WINTER GARDENS DRIVETELEPHONE:
(619) 443-6075
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 3CENSUS: 3DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:20 PM
MET WITH:Licensee Patricia WhiteTIME COMPLETED:
08:15 PM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct a required annual licensing inspection. LPA Correia identified herself and was granted entry into the facility by Licensee Patricia White who was explained the purpose of the visit.

The facility is licensed to serve six (3) clients; ages 18-59. An infection control inspection specific to COVID-19 was initiated. LPA Correia, accompanied by Licensee White, toured the facility and spoke to the clients in care. LPA observed signs posted throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing. Due to time constraints LPA Correia was unable to complete the inspection and will return at a later date to conduct the remaining portion of the inspection.

No deficiencies were cited during today’s visit. An exit interview was conducted with Licensee White. LPA Correia will provide a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) to her via email. An electronic response reply was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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