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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603148
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:46:26 PM

Document Has Been Signed on 08/31/2023 01:46 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:ANTONIO'S BOARD AND CAREFACILITY NUMBER:
374603148
ADMINISTRATOR:DULCE P. ANTONIOFACILITY TYPE:
735
ADDRESS:3737 FESTIVAL CTTELEPHONE:
(619) 271-8329
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
08/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Licensee Dulce AntonioTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Dulce Antonio.

Today's visit was in response to licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 08/29/2023. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 08/29/2023.

LPA performed a facility tour / welfare check on remaining clients, collected pertinent records, and interviewed relevant staff. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Antonio, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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