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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604112
Report Date: 02/15/2022
Date Signed: 02/16/2022 03:50:44 PM


Document Has Been Signed on 02/16/2022 03:50 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:HEAVEN'S GRACE CARE HOME 2FACILITY NUMBER:
374604112
ADMINISTRATOR:REDMAN, JONATHANFACILITY TYPE:
740
ADDRESS:629 MICHAEL STTELEPHONE:
(310) 418-5768
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 5DATE:
02/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Raymond Abedoza, CaregiverTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management visit to verify information on the updated fire clearance provided to the department on July 6, 2021. LPA identified herself, stated the purpose of the visit and was granted entry by and met with Caregiver, Raymond Abedoza.


During today's visit, LPA conducted a tour of the facility, accompanied by Mr. Abedoza. The facility sketch/floor plan was consistent with the current layout and accommodations at the facility. The request will be forwarded to management for final review and approval. Approval notification to licensee will be made by Community Care Licensing, and a new license will be mailed to the licensee after final approval.

An exit interview was conducted with Mr. Abedoza and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to the 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) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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