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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604149
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:01:17 PM


Document Has Been Signed on 03/09/2022 04:01 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:NORTH COUNTY CARE HOMEFACILITY NUMBER:
374604149
ADMINISTRATOR:CAMPAS, CARMENFACILITY TYPE:
740
ADDRESS:15042 AMSO STTELEPHONE:
(858) 842-4608
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
03/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Carmen Campas, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Miller conducted an unannounced case management visit to discuss eviction procedures. LPA was granted entry by Saraiz Romero, caregiver, after identifying herself. LPA discussed the purpose of the visit with Carmen Campas, Administrator.

Administrator sent to LPA a copy of an eviction notice given to Resident 1 (R1 - See LIC811) on 03/03/22 that did not meet the standards set forth in Title 22. LPA Miller went over Title 22, section 87224 and discussed allowed reasons for an eviction and all the elements needed in an eviction notice. R1's responsible party stated to Administrator that R1 would be moved out on 03/10/22. Administrator stated a new eviction notice would be issue if R1 was not moved out by 03/10/22.

An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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