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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603968
Report Date: 10/18/2023
Date Signed: 10/18/2023 02:00:20 PM

Document Has Been Signed on 10/18/2023 02:00 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:A.B. JESSIE POLINSKY CHILDREN'S CENTERFACILITY NUMBER:
374603968
ADMINISTRATOR:ROSAS, ELIZABETHFACILITY TYPE:
721
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 204CENSUS: 45DATE:
10/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alicia RogersTIME COMPLETED:
02:10 PM
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On October 18th, 2023 at 11:00 a.m., Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced inspection. LPA Salem met with Alicia Rogers. The purpose of the inspection is to conduct interviews regarding a case management incident.

IEU Monitor Christina Bradley was present for interviews.

LPA Salem and IEU Monitor Bradley conducted interviews with S1 and S2.

Based on information gathered, further information is needed and the case management will be extended.

An exit interview was conducted with Alicia Rogers and a signed copy of this report was provided.
Ann Valenzuela
Jacob Salem
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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