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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602810
Report Date: 03/13/2023
Date Signed: 03/13/2023 04:06:37 PM

Document Has Been Signed on 03/13/2023 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:FAIRMOUNT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
374602810
ADMINISTRATOR:NOU, SOKYFACILITY TYPE:
735
ADDRESS:4027 JUNIPER STREETTELEPHONE:
(619) 527-7057
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY: 4CENSUS: 4DATE:
03/13/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Licensee Soky NouTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) Dang Nguyen and Alyssa Ramirez conducted an unannounced Case Management visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee Soky Nou.

LPAs briefly toured the facility, performed a health and safety welfare check on clients in care, and spoke with staff. No deficiencies were observed or cited on this date.

An exit interview was conducted with Nou, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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