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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604214
Report Date: 08/11/2021
Date Signed: 08/18/2021 01:08:59 PM

Document Has Been Signed on 08/18/2021 01:08 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:JERIJAN HAPPY HOMEFACILITY NUMBER:
374604214
ADMINISTRATOR:ANTONIO, JERIJANFACILITY TYPE:
735
ADDRESS:580 JUNIPER STREETTELEPHONE:
(619) 422-2036
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 3DATE:
08/11/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caregiver, Lilia YanitTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced case management visit. LPA Hamilton was greeted at the front door by Caregiver, Lilia Yanit and granted entry after identifying herself. LPA explained the purpose of the visit.

The purpose of this visit is to ensure Client 1 (C1) (See confidential name list LIC 811) is residing in a client bedroom. During today's visit, LPA toured the facility, and verified client rooms and confirmed room #2 is designated to C1.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Caregiver Yanit and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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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