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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 04/26/2022
Date Signed: 04/26/2022 05:43:44 PM

Document Has Been Signed on 04/26/2022 05:43 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:LIBERTY TRANQUILITYFACILITY NUMBER:
374604208
ADMINISTRATOR:SMITH, DAVIDFACILITY TYPE:
737
ADDRESS:1404 ASH STREETTELEPHONE:
(760) 654-6277
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 3DATE:
04/26/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:David Smith, Program DirectorTIME COMPLETED:
01:45 PM
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 Licensing Program Analyst (LPA) Dawn Segura visited the facility to conduct an unannounced Case Management – Legal/Non-Compliance visit. The facility is currently under a non-compliance plan that includes increased monitoring and visits, and the purpose of the visit was to ensure ongoing compliance with regulations and laws and ensure the health and safety of clients in care. LPA was granted entry into the facility and met with David Smith, Program Director, with whom she discussed the purpose of the visit.

During today’s visit, LPA toured the facility, observed clients in care, and provided consultation regarding Title 22 requirements, particularly CCR 80072 Personal Rights, CCR 80061 Reporting Requirements, CCR 85161 Emergency Intervention Documentation and Reporting Requirements. LPA also discussed staff training.



No deficiencies were cited during today’s visit. An exit interview was conducted with David Smith, and a copy of this report and Licensee Rights (LIC 9058) were provided to the Program Director at the conclusion of the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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