<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603621
Report Date: 10/20/2022
Date Signed: 10/20/2022 10:17:10 AM

Document Has Been Signed on 10/20/2022 10:17 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:ACIFACILITY NUMBER:
374603621
ADMINISTRATOR:TAMARA ANDERSONFACILITY TYPE:
775
ADDRESS:296 H STREET, #101TELEPHONE:
(619) 409-4100
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 60CENSUS: 51DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Tamara AndersonTIME COMPLETED:
10:24 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LIcensing Program Analyst (LPA) Ramon Serrano conducted a Case Management visit regarding an increase in capacity application. LPA identified himself and discussed the purpose of the visit with Licensee Tamara Anderson.

Licensee applied for an increase in capacity from a total capacity of sixty (60) clients to a total capacity of ninety (90) clients of whom four (4) clients may be non-ambulatory. There is an approved Fire Clearance dated 06/01/2022 for the increase in capacity and non-ambulatory status. As of today, there are clients in care. LPA toured the facility and a had a discussion with the licensee regarding operation.

LPA toured the physical plant. Client bathrooms are equipped with cleaning products and paper towels; toxic substances are stored in a locked cabinet. Medication storage and administration logs are located in a locked box in the supervisor's office. Sufficient space to conduct activities was present; facility posting requirements were present in a common area; per the Licensee there are no guns, weapons or ammunition located on the property. Discussed with Tamara Anderson continuing operation requirements including; Covid-19 reporting requirements.

No deficiencies were issued during this visit.

An exit interview was conducted with Tamara Anderson to whom a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1