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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603824
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:03:33 PM

Document Has Been Signed on 03/25/2022 12:03 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:TIZON'S PRIME CARE INCFACILITY NUMBER:
374603824
ADMINISTRATOR:CALUMPONG, GRACEFACILITY TYPE:
735
ADDRESS:833 RANGEVIEW STREETTELEPHONE:
(619) 227-2010
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 5DATE:
03/25/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jay Miano, CaregiverTIME COMPLETED:
10:46 AM
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Licensing Program Analyst (LPA) Tiffany Holmes and Marisela Garcia- Centeno made an unannounced collateral visit to the facility to conduct an interview with consumer #1 (C1). LPAs Holmes and Garcia- Centeno was greet by caregiver Jay Miano and we discussed the reason for the visit.

During today's visit LPAs conducted an interview with consumer #1 (C1).

No deficiencies were observed during the visit. An exit interview was conducted with Licensee, to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) were provided to via email. An email receipt confirms the acknowledgement of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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