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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603587
Report Date: 08/07/2024
Date Signed: 08/07/2024 06:41:24 PM

Document Has Been Signed on 08/07/2024 06:41 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CHANCELLOR HOMEFACILITY NUMBER:
374603587
ADMINISTRATOR/
DIRECTOR:		ASTRID GARCIAFACILITY TYPE:
735
ADDRESS:13904 CHANCELLOR WAYTELEPHONE:
(858) 842-4534
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 4CENSUS: 4DATE:
08/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Administrator D'ana NunezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit. LPA Correia identified herself and met with Administrator Nunez.

Community Care Licensing received an incident report on August 6, 2024 regarding Client #1 (C1) who eloped from the facility on August 5, 2024.

During today's visit, LPA interviewed the facility Administrator Nunez and obtained copies of facility records, and conducted a brief tour. No deficiencies were cited during today’s visit.

An exit interview was conducted, and a copy of this report and the Licensee/Appeal Rights (LIC 9058 1/16) was provided to Administrator Nunez at the conclusion of the visit, and her signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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