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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603705
Report Date: 07/22/2021
Date Signed: 07/22/2021 03:40:58 PM

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:HEAVEN'S GRACE CARE HOMEFACILITY NUMBER:
374603705
ADMINISTRATOR:REDMAN, JONATHANFACILITY TYPE:
740
ADDRESS:113 POLK STREETTELEPHONE:
(760) 216-6706
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 3DATE:
07/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jonathan Redman, Wilma CabreraTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA), Kristina Ryan and Licensing Program Manager, LPM Simon Jacob, conducted an unannounced case management visit. LPA and LPM introduced themselves and were allowed entry into the facility by Caregiver Gina Baluyot and explained the purpose of the visit to Administrators, Wilma Cabrera and Jonathan Redman.

Today’s visit was in response to an eviction notice given to Resident 1 (R1) (See LIC 811 Confidential Names List) on May 05, 2021. During today’s visit LPA and LPM interviewed staff and residents, requested copies of facility records and toured the facility.

Based on today's inspection, no deficiencies were observed. An Advisory Note (LIC 9102) was issued to assist the licensee in understanding and complying with the applicable Title 22 regulations for admissions.

An exit interview was conducted with Jonathan Redman and Wilma Cabrera. A copy of this report, LIC 811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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