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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603474
Report Date: 02/07/2023
Date Signed: 02/08/2023 08:30:03 AM


Document Has Been Signed on 02/08/2023 08:30 AM - 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:ISLAND GROVE GUEST HOMEFACILITY NUMBER:
374603474
ADMINISTRATOR:MARIA C WILLIAMSFACILITY TYPE:
740
ADDRESS:2150 WASHINGTON STTELEPHONE:
(619) 410-3002
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:6CENSUS: 0DATE:
02/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Maria WilliamsTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted a case management visit regarding licensee-initiated facility closure. LPA identified himself to and discussed the purpose of the visit with Licensee Maria Williams, who joined the visit via phone.

On 10-10-2022, Licensee notified CCLD that the facility ceased operations on 10-07-2022, and that there were no residents in care. Licensee said the last resident had moved out in mid-2022, all licensing posting had been taken down, and the facility’s original license was shredded.

LPA spoke with the first property owner / landlord (P1) who was active during the period that the property was a licensed care facility. P1 confirmed the last resident moved out of the facility during May 2022. P1 said they since sold the property to a new owner (P2) on 07-29-2022. Per their interview, P2 verified there were no residents in care when they purchased the property, and that the property is currently their private residence.

During today’s visit, LPA briefly visited the facility’s address, seeing no indication of residents in care. No deficiencies were issued, and the facility is ready for closure in the licensing system. An exit interview was conducted with Williams, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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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