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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604269
Report Date: 06/27/2023
Date Signed: 06/27/2023 02:14:53 PM


Document Has Been Signed on 06/27/2023 02:14 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:FELICITA VIDAFACILITY NUMBER:
374604269
ADMINISTRATOR:MALASPINA, KIMBERLYFACILITY TYPE:
740
ADDRESS:930 MONTICELLO DRIVETELEPHONE:
(760) 747-4888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:123CENSUS: 83DATE:
06/27/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kim Malaspina, Executive DirectorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived to the facility conducted an unannounced collateral visit regarding a complaint allegation which occurred at another facility. During today's visit, LPA interviewed one staff and Resident #1(R1).

An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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