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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
374603758
Report Date:
10/24/2024
Date Signed:
10/24/2024 12:04:54 PM
Document Has Been Signed on
10/24/2024 12:04 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:
LIBEY'S ARF-AVOCADO
FACILITY NUMBER:
374603758
ADMINISTRATOR/
DIRECTOR:
HURTADO-AYUP, MARIE
FACILITY TYPE:
735
ADDRESS:
4402 AVOCADO BLVD
TELEPHONE:
(619) 334-9415
CITY:
LA MESA
STATE:
CA
ZIP CODE:
91941
CAPACITY:
4
CENSUS:
3
DATE:
10/24/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:59 AM
MET WITH:
Samuel Hurtado, Licensee
TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Completion of the Annual Inspection Tool. No deficiencies were sited for this Annual Visit
SUPERVISORS NAME
:
Denise Powell
LICENSING EVALUATOR NAME
:
Renita Hall
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/24/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2024
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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