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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603621
Report Date: 01/20/2023
Date Signed: 01/20/2023 08:53:20 AM

Document Has Been Signed on 01/20/2023 08:53 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: 90CENSUS: 42DATE:
01/20/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Licensee, Tamera AndersonTIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA), Elizabeth Hamilton conducted an unannounced collateral visit. LPA was greeted at the front entrance by, Program Supervisor, Yvonne Samora and granted entry after identifying herself. LPA met with Licensee, Tamera Anderson explained the purpose of the visit, to interview a client.

During today's visit, LPA briefly toured the facility and interviewed a client. No deficiencies were observed during the visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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