<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604057
Report Date: 04/16/2024
Date Signed: 04/16/2024 01:34:21 PM


Document Has Been Signed on 04/16/2024 01:34 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:PLATEAU VILLAGE MEMORY CAREFACILITY NUMBER:
374604057
ADMINISTRATOR:AYERSMAN, JENNIEFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:0CENSUS: 0DATE:
04/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Report mailed due to facility closure June 7, 2023TIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Marisela Garcia-Centeno, sent this report to the former Licensee's last known mailing address via USPS certified mail to deliver an Amended Report for the the investigation findings for the allegations on the report mailed on 3/15/2024. The facility was closed on June 7, 2023.


A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was mailed to the last known Licensee’s address due to the closure of the facility in June 2023.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1