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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:23:18 AM

Document Has Been Signed on 01/31/2023 11:23 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:LIBERTY TRANQUILITYFACILITY NUMBER:
374604208
ADMINISTRATOR:SMITH, DAVIDFACILITY TYPE:
737
ADDRESS:1404 ASH STREETTELEPHONE:
(760) 654-6277
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 4DATE:
01/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:David Smith, Program DirectorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Dawn Segura made an unannounced case management visit to the facility to obtain signatures on an amended report. The report was originally created during a complaint investigation visit that occurred on January 13, 2023. After introducing herself, LPA was granted entry into the facility and met with David Smith, Program Director, to whom she disclosed the purpose of the visit.

During the visit, LPA reviewed and obtained signatures on the amended report.

An exit interview was conducted, and copies of this report, the amended report, and Licensee Rights (LIC 9058) were provided to David Smith at the conclusion of the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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