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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604158
Report Date: 06/07/2024
Date Signed: 06/07/2024 04:07:30 PM


Document Has Been Signed on 06/07/2024 04:07 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SERENE RICHVIEWFACILITY NUMBER:
374604158
ADMINISTRATOR:CHAN, JEFFREYFACILITY TYPE:
740
ADDRESS:1086 CALLE MESITATELEPHONE:
(619) 475-4244
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY:6CENSUS: 2DATE:
06/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Caregiver, Chan JessieTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required 1-Year Visit. LPA was greeted by, Caregiver, Jessie Chan to whom she identified herself and discussed the purpose of the visit. All staff present have a current criminal record clearance.

An annual inspection was not conducted during this visit because CCL conducted an annual inspection on March 18, 2024. No concerns or violations were cited during the inspection.

During today's visit, LPA conducted case management to follow up regarding bathroom accommodations for one resident.

No violations were observed during today’s visit.

An exit interview was conducted with Caregiver, Jessie Chan, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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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