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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602824
Report Date: 09/28/2023
Date Signed: 09/29/2023 11:01:39 AM

Document Has Been Signed on 09/29/2023 11:01 AM - 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:CPSRC BMDTP-LAKESIDEFACILITY NUMBER:
374602824
ADMINISTRATOR:NANCY ELDRIDGEFACILITY TYPE:
775
ADDRESS:11757 TOPO LANETELEPHONE:
(619) 561-7405
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 30CENSUS: 30DATE:
09/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH: Assistant Director Crystal CaveTIME COMPLETED:
03:00 PM
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The Licensing Program Analyst (LPA) Debbie Correia conducted an announced Case Management visit, identified herself to Assistant Director Crystal Cave, and discussed the purpose of the visit.

LPA Correia conducted the Case Management visit to secure records regarding an incident that occurred on July 31,2023 involving Client (C1) and Client 2 (C2). LPA requested records and Assistant Director Cave was advised further investigation is needed before determining findings.

No deficiencies were cited during today's visit.

An exit interview was conducted with Assistant Director Cave. A copy of this report along with Licensee Rights (LIC9058 01/16) was provided to Assistant Director Cave and signature below confirms receipt of the reports.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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