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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603447
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:48:32 PM


Document Has Been Signed on 03/30/2022 02:48 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,
, CA



FACILITY NAME:ST. PANTELEIMON ELDERCAREFACILITY NUMBER:
374603447
ADMINISTRATOR:SIMON QUEZONFACILITY TYPE:
740
ADDRESS:1537 TIBIDABO DRIVETELEPHONE:
(760) 294-2743
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 0DATE:
03/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Licensee Miriam GavrilkinaTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPAs) Liliana Silveira conducted a case management visit. LPA Silveira identified herself and explained the process of the facility closure with Licensee Miriam Gavrilkina.

During today's visit LPA toured the facility and verified there are no clients in care and designated rooms are not occupied. The LPA interviewed Licensee Miriam Gavrilkina and obtained her statement verifying the facility is voluntarily closing. The Licensee also surrendered the original copy of the license to LPA.

An exit interview was conducted with Licensee Miriam Gavrilkina and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to her via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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