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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603155
Report Date: 06/09/2023
Date Signed: 06/09/2023 01:51:16 PM


Document Has Been Signed on 06/09/2023 01:51 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:LILAC CHATEAU 1FACILITY NUMBER:
374603155
ADMINISTRATOR:WITHERS, KIMBERLYFACILITY TYPE:
740
ADDRESS:9718 EUCALYPTUS COURTTELEPHONE:
(619) 312-1494
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 6DATE:
06/09/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Kimberly Withers, LicenseeTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced collateral visit to the facility to obtain records and conduct staff interviews. LPA Lopez identified herself and was granted entry by Victoria Sumalinog, caregiver. Staff Jovy Fronda, caregiver was also present at the facility. LPA stated the purpose of the visit with Kimberly Withers, Licensee.

During the visit, LPA Lopez interviewed staff #1 (S1), and Staff #2 (S2), and requested relevant documents. No deficiencies were observed during today's visit.

An exit interview was conducted, and a copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) were provided to Victoria Sumalinog, caregiver, at the conclusion of the visit. The signature below confirms the receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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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