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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602717
Report Date: 12/14/2022
Date Signed: 12/14/2022 12:22:22 PM

Document Has Been Signed on 12/14/2022 12:22 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:JENKINS, MAKAILA AFACILITY TYPE:
735
ADDRESS:1504 WHITESTONE ROADTELEPHONE:
(619) 825-8487
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 3DATE:
12/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:House Manager Marvasia SmithTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA), Kayla Hilario conducted an unannounced case management visit. LPA identified herself, discussed the purpose of the visit, and met with House Manager Marvasia Smith.

Today’s visit was regarding an incident leading to the request of a three day eviction. During today’s visit LPA interviewed staff and collected resident records. LPA toured the facility both inside and outside. All clients were away from the facility.

Based on today's inspection, no deficiencies were cited or observed.

An exit interview was conducted with House Manager Marvasia Smith. A copy of this report, and the Licensee/Appeal Rights (9058 03/2022) were provided via hardcopy at the conclusion of the visit.

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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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