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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603798
Report Date: 11/30/2021
Date Signed: 12/01/2021 11:37:06 AM

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:BLUEBERRY HILL MANORFACILITY NUMBER:
374603798
ADMINISTRATOR:DIZON, CAROLINAFACILITY TYPE:
740
ADDRESS:13227 BLUEBERRY HILL LANETELEPHONE:
(760) 518-8508
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY:0CENSUS: DATE:
11/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Fangli Wang and Jun LiTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Manager (LPM) Simon Jacob and Licensing Program Analyst (LPA) Sabel Martinez
conducted an unannounced closure visit to the facility. LPM and LPA were greeted by Administrator Fangli Wang and Jun Li, identified themselves and disclosed the purpose of the visit. On November 8, 2021, LPA Martinez received notification of facility closure from Administrator Fangli Wang.

During the closure visit, LPM and LPA observed the facility to be vacant with no clients residing at the facility. Prior to the closure visit, proper eviction notices and proper relocation of clients was confirmed with responsible parties and current facilities. As of today, no deficiencies were issued and the facility is considered closed.

An exit interview was conducted with Administrator Wang and Li. A copy of this report and Licensee's Appeal Rights (LIC 9058 01/16) were provided to the Licensee and Administrator via e-mail. A confirmation receipt has been requested.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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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