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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602441
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:18:52 PM

Document Has Been Signed on 11/02/2023 02:18 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:SAM & ROSE STEIN EDUCATION CENTERFACILITY NUMBER:
374602441
ADMINISTRATOR:PONCE, SERGIOFACILITY TYPE:
775
ADDRESS:4990 WILLIAMS AVETELEPHONE:
(619) 463-3300
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 45CENSUS: 43DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Program Supervisor Melinda WilliamsTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Program Supervisor Melinda Williams.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 09/18/2023), involving Client #1 (C1). [See LIC 811 Confidential Names List for a description of C1].

During today’s visit, LPA performed a facility tour and welfare check on C1, finding they were safe. LPA also collected copies of pertinent records and interviewed relevant staff.

No deficiencies were cited during today's visit. LPA provided Technical Assistance (TA) regarding the facility’s doors.

An exit interview was conducted with Williams, to whom a copy of this report, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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