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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602755
Report Date: 06/30/2021
Date Signed: 06/30/2021 10:24:53 AM

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:HOLY ROSARY RESIDENCEFACILITY NUMBER:
374602755
ADMINISTRATOR:LEE, ELIZABETHFACILITY TYPE:
740
ADDRESS:5651 DOROTHY WAYTELEPHONE:
(619) 582-2422
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:6CENSUS: 0DATE:
06/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Elizabeth LeeTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted a Case Management - Other visit regarding licensee initiated facility closure. LPA was greeted by, identified himself to, and discussed the purpose of the visit with licensee Elizabeth Lee.

On 06-14-2021, Lee submitted a letter to the CCLD regional office stating that the facility had ceased operations and closed as of 12-30-2020. LPA verified that all residents were successfully relocated prior to 12-30-2020.

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. The facility is ready for closure.

An exit interview was conducted with Lee, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A copy of these documents were also mailed to her via regular USPS mail.

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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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