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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603681
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:52:46 PM

Document Has Been Signed on 06/08/2022 03:52 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:KP DISABILITY SERVICEFACILITY NUMBER:
374603681
ADMINISTRATOR:POLLARD, KIMFACILITY TYPE:
735
ADDRESS:2775 VISTA SERENO CTTELEPHONE:
(619) 713-6551
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 6CENSUS: DATE:
06/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Caregiver Elizabeth Flores TIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA), Kayla Hilario, conducted an unannounced case management visit to discuss an incident report. LPA was allowed entry and met with Caregiver Elizabeth Flores. LPA identified herself, discussed the purpose of the visit.

All caregivers had current criminal record clearance. LPA discovered that the client from the incident report resides at KP Disability Service 2 located at 8350 Golden Avenue. LPA will follow-up with other facility.

An exit interview was conducted with Caregiver Elizabeth Flores. The Caregiver was provided a copy of Licensee Rights (LIC 9058 01/16), and a copy of this report via hardcopy at the conclusion of the visit.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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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