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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603857
Report Date: 11/18/2022
Date Signed: 12/30/2022 02:48:40 PM

Document Has Been Signed on 12/30/2022 02:48 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:OPEN ARMS II ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
374603857
ADMINISTRATOR:WATKINS, JERRYFACILITY TYPE:
735
ADDRESS:9515 DATE ST.TELEPHONE:
(619) 368-0626
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 5DATE:
11/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Ethel Gray, AdministratorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced case management visit to deliver amended reports from a complaint investigation. LPA met with administrator Ethel Gray and explained the reason for this visit. During today's visit, LPA delivered findings for the amended D page from 09/30/2022. An exit interview was conducted, plan of correction was already completed and cleared and a copy of this report along with licensee rights and a copy of the amended report, were provided to Gray, administrator whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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