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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602750
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:06:41 PM

Document Has Been Signed on 06/14/2022 04:06 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:ELMIRA HOME CAREFACILITY NUMBER:
374602750
ADMINISTRATOR:JENKINS, VALERIEFACILITY TYPE:
735
ADDRESS:361 ELMIRA STREETTELEPHONE:
(619) 749-9761
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 4CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Director Valerie JenkinsTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Director Valerie Jenkins and discussed the purpose of the visit.

Community Care Licensing received an incident report on 6/13/2022 in which it was reported that Client #1 (C1) went absent without official leave (AWOL) from the hospital on 6/11/2022 and has not returned. Per records reviewed licensee followed absentee notification plan as necessary.

During today's visit, LPA conducted a health and safety check of the clients in care and provided consultation. No deficiencies were cited during today’s visit.

Director Valerie Jenkins was provided a copy of this report, appeal rights (LIC9058 01/16) and a LIC 811.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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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