<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602528
Report Date: 07/17/2024
Date Signed: 07/17/2024 08:05:12 PM


Document Has Been Signed on 07/17/2024 08:05 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:ANSHIN HOME CAREFACILITY NUMBER:
374602528
ADMINISTRATOR:TODA, KUNINOBUFACILITY TYPE:
740
ADDRESS:9412 HILMER DRIVETELEPHONE:
(619) 867-2341
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 0DATE:
07/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Osorio AdministratorTIME COMPLETED:
01:53 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Amy Domingo conducted a case management visit regarding licensee initiated facility closure. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Maria Osorio, Administrator.

On 07/10/2024, Maria Osorio submitted a letter to the CCLD regional office stating that the facility had ceased operations and closed on 07/17/2024. LPA verified that all residents were successfully relocated prior to 07/17/2024.

During today's visit, LPA briefly toured the facility and verified that there were no residents in care. All resident clothing and personal effects have been removed. All licensing postings have been removed. LPA obtained the facility's original license. No deficiencies were issued, and the facility is ready for closure.

An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (3/22) were left with the Administrator Maria Osorio, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1