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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601939
Report Date: 08/09/2022
Date Signed: 08/09/2022 04:12:17 PM

Document Has Been Signed on 08/09/2022 04:12 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:SPECIAL FRIENDS-SAGEWOODFACILITY NUMBER:
374601939
ADMINISTRATOR:WOJCIECHOWSKI, MICHELLEFACILITY TYPE:
735
ADDRESS:13411 SAGEWOOD DRIVETELEPHONE:
(858) 312-1687
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
08/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Michelle Wojciechowsky, AdministratorTIME COMPLETED:
02:08 PM
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced visit for an unrelated investigation. LPA was granted entry after identifying herself by Katherine Carver, House Manager. House Manager was not wearing a mask and was unclear on visitation procedures.

House Manager stated that she was hired about a month ago and did not know what Title 22 was nor what Community Care Licensing was. LPA briefly educated House Manager on COVID procedures such as temperature checks, visitation policy, mask requirements, vaccination and booster requirements, and reporting requirements. LPA also introduced House Manager to the Department's website and Provider Information Notices.

An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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