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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604061
Report Date: 09/17/2021
Date Signed: 09/20/2021 11:26:46 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:CASA CIELOFACILITY NUMBER:
374604061
ADMINISTRATOR:ALLAN, BRETT KFACILITY TYPE:
740
ADDRESS:17737 HUNTERS RIDGE ROADTELEPHONE:
(619) 990-0543
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:6CENSUS: 6DATE:
09/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Leticia Velatorre, CaregiverTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Laarni Santiago conducted an unannounced case management visit to deliver an amended report. LPA was met by Caregiver, Leticia Velatorre, and was granted entry into the facility and discussed the purpose of the visit.

During today's visit, LPA delivered an amended Facility Report - LIC 9099-D, dated May 16th, 2019.

An exit interview was conducted with Caregiver, and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to Administrator via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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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