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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604120
Report Date: 07/26/2023
Date Signed: 07/26/2023 06:21:08 PM

Document Has Been Signed on 07/26/2023 06:21 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:HUMMINGBIRD HEALING HOUSEFACILITY NUMBER:
374604120
ADMINISTRATOR:TATUNAY, NICOLEFACILITY TYPE:
772
ADDRESS:5550 UNIVERSITY AVE STE BTELEPHONE:
(619) 481-6790
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY: 15CENSUS: 15DATE:
07/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:PM Shift Lead / Service Coordinator Jenaya JohnsonTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to observe the physical plant. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with PM Shift Lead / Service Coordinator Jenaya Johnson.

On 07/03/2023, the Licensee submitted an LIC200 Application and updated facility sketch to the CCLD San Diego Regional Office (RO), seeking to increase the facility's total licensed capacity from 15 clients up to 18 clients. The application did not request any changes to non-ambulatory or bedridden capacity.

On 07/10/2023, the local fire authority approved/granted an updated fire clearance, reflecting the facility was approved for 18 clients in total, all of whom must be ambulatory.

During today’s visit, LPA briefly toured the interior and exterior of the facility. The facility sketch/floor plan was consistent with the current layout of the facility. No deficiencies were observed or cited during today's visit

This portion of the application process has been completed. The Licensee will be sent an updated license to reflect the new fire clearance after CCLD management’s final review and approval.


An exit interview was conducted with Johnson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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