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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603596
Report Date: 01/19/2024
Date Signed: 01/22/2024 05:21:25 PM

Document Has Been Signed on 01/22/2024 05:21 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:PEOPLE'S CARE JOHNSON LAKEFACILITY NUMBER:
374603596
ADMINISTRATOR:SILVIA DAVALOSFACILITY TYPE:
735
ADDRESS:11691 JOHNSON LAKE DRTELEPHONE:
(619) 390-1380
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 4CENSUS: 4DATE:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Silvia DavalosTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and identified themselves to Administrator Silvia Davalos. LPA discussed the purpose of the visit with Silvia Davalos.

During today’s visit, LPAs briefly toured the facility, reviewed resident records, and interviewed staff and residents. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection.

An exit interview was conducted with Silvia, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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