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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604149
Report Date: 08/02/2022
Date Signed: 08/02/2022 11:12:43 AM


Document Has Been Signed on 08/02/2022 11:12 AM - 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: 5DATE:
08/02/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sandy PalaciosTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Collateral visit. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Caregiver Sandy Palacios.

During today's visit, LPA attempted to interview a resident for a complaint investigation lodged against another facility licensed by Community Care Licensing. Sandy stated that the resident no longer lived at this facility.

An exit interview was conducted with Sandy Palacios, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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