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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601046
Report Date: 11/09/2022
Date Signed: 11/09/2022 01:36:28 PM


Document Has Been Signed on 11/09/2022 01:36 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BROOKDALE PLACE OF SAN MARCOSFACILITY NUMBER:
374601046
ADMINISTRATOR:PRESTON, MARIOFACILITY TYPE:
740
ADDRESS:1590 W SAN MARCOS BLVDTELEPHONE:
(760) 471-9904
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:245CENSUS: 163DATE:
11/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Debbie Spence, Business Office ManagerTIME COMPLETED:
01:40 PM
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On November 9, 2022, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility for the purpose of investigating the complaint number 18-AS-20220606112050. At the time of visit, LPA met with Business Office Manager, Debbie Spence and explained the purpose of the visit.

During today’s visit LPA conducted interviews with residents. No deficiencies were cited during today’s visit.

An exit interview was conducted where this report and LIC811 was discussed with and provided to Debbie Spence.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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