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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601876
Report Date: 01/08/2025
Date Signed: 01/09/2025 11:06:47 AM

Document Has Been Signed on 01/09/2025 11:06 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MOFFAT'S ROSE HOMEFACILITY NUMBER:
374601876
ADMINISTRATOR/
DIRECTOR:		TRINA PACKARDFACILITY TYPE:
735
ADDRESS:9019 ILDICA STTELEPHONE:
(619) 460-2030
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 6DATE:
01/08/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Trina Packard, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an announced Case Management visit on this date. LPA arrived to do the annual and Administrator stated that a staff had scabies and that all clients were being treated although none of them have been diagnosed with it. LPA decided for their safety to return on another date to conduct the annual.

An exit interview was conducted this report was discussed and a copy was given to Trina Packard, Administrator
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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