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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603212
Report Date: 04/22/2022
Date Signed: 04/22/2022 03:45:21 PM


Document Has Been Signed on 04/22/2022 03:45 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:GOLD CANYON CARE HOMEFACILITY NUMBER:
374603212
ADMINISTRATOR:STOLZ, ARMINFACILITY TYPE:
740
ADDRESS:6461 QUILLAN STREETTELEPHONE:
(858) 836-1111
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:6CENSUS: 4DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Armin StolzTIME COMPLETED:
02:33 PM
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Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with licensee Armin Stolz and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

An exit interview was conducted with Armin Stolz A copy of this report along with Licensee Rights (LIC 9098, 01/16) was provided to Armin Stolz whose signature below verifies receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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