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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603669
Report Date: 11/20/2024
Date Signed: 11/20/2024 11:44:00 PM

Document Has Been Signed on 11/20/2024 11:44 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:HABILITATIVE HOMES RESIDENTIAL CARE FACILITYFACILITY NUMBER:
374603669
ADMINISTRATOR/
DIRECTOR:		DAVID LARSONFACILITY TYPE:
735
ADDRESS:11775 WALNUT ROADTELEPHONE:
(619) 938-4007
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 6DATE:
11/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Licensee LarsonTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Case Management Visit. LPA identified herself and met with Licensee/Administrator Larson, and discussed the purpose of the visit.

Today's visit is in response incident reports received by the Department.

During today's visit LPA Correia collected pertinent records, staff interviews, and secured photos.

There were no deficiencies cited during today's visit

An exit interview was conducted and a copy of this report will be provided to Licensee/Administrator Larson, and signature on this form, acknowledges receipt of these rights
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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