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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600944
Report Date: 04/28/2021
Date Signed: 05/05/2021 12:48:50 PM

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:EVENING SHADE MANOR,INC.FACILITY NUMBER:
374600944
ADMINISTRATOR:PATSY A. FOSTERFACILITY TYPE:
740
ADDRESS:386 SANDY STREETTELEPHONE:
(619) 444-2282
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:6CENSUS: 0DATE:
04/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Breanna Vildibill, Licensee's RepresentativeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Laarni Santiago initiated a virtual visit via FaceTime to finalize the facility's closure. LPA identified herself and discussed the purpose of the visit with Licensee's authorized representative, Breanna Vildibill..

On March 22nd, 2021, LPA was notified that the facility will plan to close due to personal reasons. On April 14th, 2021, CCLD received notification that all the residents have relocated and the facility ceased operation with an effective date of April 12th, 2021. All relocation information of the residents were provided to LPA. During today's tele-visit, LPA toured the facility, verified that there were no residents in care, and requested for the original license to be submitted to the department.

A virtual exit interview was conducted with Ms. Vildibill, and the Licensee/Appeal Rights (LIC 9058 01/16) along with a copy of this report was emailed to Licensee. A read receipt from Licensee will confirm receipt of documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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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