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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602092
Report Date: 05/16/2022
Date Signed: 05/17/2022 08:12:23 AM


Document Has Been Signed on 05/17/2022 08:12 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:FRIENDLY HOME IIFACILITY NUMBER:
374602092
ADMINISTRATOR:RONDA GAMBLE-HOLMESFACILITY TYPE:
735
ADDRESS:504 RITCHEY STTELEPHONE:
(619) 263-2127
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:22CENSUS: 18DATE:
05/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver Luz SantosTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA), Kayla Hilario, conducted an unannounced case management visit to amend a report that was created on 04/27/2022. LPA identified herself, discussed the purpose of the visit and met with Caregiver Luz Santos.

During the visit, LPA explained the amended 9099 page and obtained signature on the amended report. An exit interview was conducted with Caregiver Luz Santos. The amended report, Licensee Rights (LIC 9058 01/16), and a copy of this report was provided to via hardcopy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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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