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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603688
Report Date: 04/13/2023
Date Signed: 04/13/2023 10:56:32 AM


Document Has Been Signed on 04/13/2023 10:56 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SAPPHIRE CHARDONNAYFACILITY NUMBER:
374603688
ADMINISTRATOR:NAGHIBI, ALIFACILITY TYPE:
740
ADDRESS:484 CHARDONNAY COURTTELEPHONE:
(760) 539-7791
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:6CENSUS: 6DATE:
04/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Elizabeth Rivera, AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analysts (LPAs) Stephanie Torres and Sara Martinez conducted an unannounced case management visit to amend LIC 9099 reports created on 12/21/2022, relating to complaint #18-AS-20221219140229. The LPAs identified themselves and discussed the purpose of the visit with Administrator, Elizabeth Rivera.

The amended reports and a copy of this report were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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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