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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 09/14/2023
Date Signed: 09/14/2023 10:26:34 AM

Document Has Been Signed on 09/14/2023 10:26 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:
09/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Lead Behavioral Support Professional Victoria BurnsTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to deliver an amended LIC9099 report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Lead Behavioral Support Professional Victoria Burns.

During today’s visit, LPA obtained Victoria Burns' signature on the amended complaint report dated March 9, 2022.

An exit interview was conducted with Lead Behavioral Support Professional Victoria Burns, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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