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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602208
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:37:55 PM


Document Has Been Signed on 05/08/2024 04:37 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SARASONA HOME CAREFACILITY NUMBER:
374602208
ADMINISTRATOR:ESTHER V. CAMAGAYFACILITY TYPE:
740
ADDRESS:3717 SARASONA WAYTELEPHONE:
(619) 434-6998
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY:6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Caregiver, Leodivina PanTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Case Management visit to deliver an Amended Report for a visit conducted on December 14, 2022. LPA was greeted by, Caregiver, Leodivina Pan to whom she identified herself and discussed the purpose of the visit. All staff present have a current criminal record clearance.

During today's visit, LPA obtained Caregiver, Leodivina Pan, signature on the amended report LIC9099, LIC9099A, and LIC9099D dated 5/8/2024.

An exit interview was conducted and a copy of this report along with the Licensee's Rights (LIC9058 03/22) was provided to Caregiver, Leodivina Pan. Signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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