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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601395
Report Date: 10/14/2024
Date Signed: 10/15/2024 08:29:01 AM


Document Has Been Signed on 10/15/2024 08:29 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:PARADISE VALLEY MANORFACILITY NUMBER:
374601395
ADMINISTRATOR:AARON BURRUPFACILITY TYPE:
741
ADDRESS:2575 E. EIGHTH STREETTELEPHONE:
(619) 470-6700
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:50CENSUS: 34DATE:
10/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Med Tech Monica JacoboTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management Visit.  LPA met with Med Tech Monica Jacobo to discuss the purpose of the visit. 

Today's visit is in response to the self reported incident report Regional Office received on 9/11/2024 involving R1 [see 811 confidential names].

LPA interviewed facility staff and obtained facility records. No deficiencies were cited or observed on this date. 

An exit interview was conducted with Jacobo who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
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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