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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603339
Report Date: 10/28/2020
Date Signed: 11/02/2020 09:51:55 AM

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:MERIDIAN AT LAKE SAN MARCOS, THEFACILITY NUMBER:
374603339
ADMINISTRATOR:QUIGLEY, KEVINFACILITY TYPE:
740
ADDRESS:1177 SAN MARINO DR BLDG 1 & 2TELEPHONE:
(760) 510-7500
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:170CENSUS: DATE:
10/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director Kevin QuigleyTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Raymond Wu conducted a virtual Case Management visit on this date. LPA contacted Executive Director Kevin Quigley and discussed the purpose of the visit.

The visit was in response to a self-reported Incident Report (LIC 624) received by the Regional Office on October 22, 2020. Additional information was obtained on this date regarding the incident that occurred. Interviews were conducted and records were requested.

No deficiencies were cited or observed on this date.

The Licensee was provided a copy of their appeal rights (LIC9058 01/16), and their authorized representative's signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided to Executive Director Kevin Quigley via electronic mail. An electronic read receipt confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Raymond WuTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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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