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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604153
Report Date: 02/17/2022
Date Signed: 02/17/2022 08:25:17 PM

Document Has Been Signed on 02/17/2022 08:25 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:BLOOMING CARE RESIDENTIALFACILITY NUMBER:
374604153
ADMINISTRATOR:GAVIOLA, MARGARITAFACILITY TYPE:
735
ADDRESS:6384 PLAZA CUERNAVACATELEPHONE:
(619) 791-8095
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 4CENSUS: 4DATE:
02/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:12 PM
MET WITH:Margarita Gaviola, LicenseeTIME COMPLETED:
11:35 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing. LPA introduced herself, was granted entry into the facility, and met with Margarita Gaviola, Licensee, to whom she disclosed the purpose of the visit.

Community Care Licensing received an incident report on February 14, 2022, in which it was reported that Client #1 (C1) [Licensee was provided an LIC 811 Confidential Names List that identifies the client] went absent without official leave (AWOL) from the facility on February 13, 2022 and was returned on February 15, 2022.

During today's visit, LPA conducted a health and safety check of the clients in care, interviewed licensee and C1, provided consultation, and obtained copies of facility records. No deficiencies were cited during today’s visit.

An exit interview was conducted with Margarita Gaviola, and a copy of this report and Licensee Appeal Rights (LIC 9058) were provided to the licensee, via electronic mail, following the visit. An electronic mail read receipt confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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