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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602023
Report Date: 08/02/2022
Date Signed: 08/02/2022 03:23:03 PM


Document Has Been Signed on 08/02/2022 03:23 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:PASCUA RCFEFACILITY NUMBER:
374602023
ADMINISTRATOR:JESUSA PASCUAFACILITY TYPE:
740
ADDRESS:1268 STAMEN STTELEPHONE:
(619) 266-0179
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:4CENSUS: DATE:
08/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Caroline Belarmino, Caregiver, and Licensee Jesusa PascuaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection and provided facility with additional guidance. LPA identified herself and was granted entry by Caroline Belarmino, caregiver. LPA met with caregiver Belarmino and discussed the purpose of today’s visit. Licensee Jesusa Pascua later arrived and joined the visit.

During today’s visit, LPA toured the facility accompanied by caregiver Belarmino. LPA provided guidance to Licensee Pascua on Title 22, Division 6, Chapter 8, Section 87211 Reporting Requirements, resident records and provided a copy of the Records to be Maintained at the Facility (LIC311F) form. Based on today’s inspection no deficiencies were cited.

An exit interview was conducted with Licensee Pascua. A copy of this report, along with the Licensee Rights (01/2016) was provided to Licensee Pascua at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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