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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602717
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:42:10 PM

Document Has Been Signed on 11/18/2021 01:42 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:M & M RESIDENTIALFACILITY NUMBER:
374602717
ADMINISTRATOR:SMITH, MARVASIAFACILITY TYPE:
735
ADDRESS:1504 WHITESTONE ROADTELEPHONE:
(619) 825-8487
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 4DATE:
11/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Chanelle Shipley, Caregiver and
Marvasia Smith Adminsitrator		TIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA), Tiffany Holmes conducted an unannounced case management visit. LPA Holmes introduced herself and was allowed entry into the facility and explained the purpose of the visit to Administrator Marvasia.

Today’s visit was regarding a case management to touch basis on Title 17 monitoring. During today’s visit LPA interviewed staff and spoke with staff regarding the non compliant Title 17 quality assurance report that documented consumer records were located in an unsecured place. Administrator Marvasia put the data control binders in the locked closet with the other confidential binders.

Based on today's inspection, no deficiencies were observed. The facility was given an advisory note regarding the client binders.

An exit interview was conducted with Marvasia and Mikayla, Administrators. A copy of this report, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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