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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603669
Report Date: 10/11/2024
Date Signed: 10/11/2024 05:17:50 PM

Document Has Been Signed on 10/11/2024 05:17 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:
10/11/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Caregiver CisnerosTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit Caregiver Cisneros.


On the CCLD San Diego Regional Office met with the licensee for a Non-Compliance Conference (NCC).

During today’s visit, LPA conducted a general tour of the facility, and performed a welfare check on resident in care. LPA briefly spoke to a resident in care. LPA confirmed the Licensee is in compliance as set forth in the Non-Compliance Plan.

No deficiencies were cited during today's visit.

An exit interview was conducted with Caregiver Cisneros, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) will be provided at the conclusion of the visit. Signature below acknowledges receipt of the reports.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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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