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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604277
Report Date: 07/26/2021
Date Signed: 07/26/2021 02:21:13 PM

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:SAFE HARBOR ELDER CAREFACILITY NUMBER:
374604277
ADMINISTRATOR:RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:3301 LOMAS SERENAS DRIVETELEPHONE:
(619) 791-5495
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:6CENSUS: 5DATE:
07/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Gauravi RathiTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Eva Torres conducted a case management visit to amend a report that was created on 06/09/21. LPA Torres met with Mr. Rathi, informed them of the purpose of the visit, and was granted entry. During the visit, LPA obtained their signature on the amended report. An exit interview was conducted, Licensee Rights (LIC 9058 01/16) along with a copy of this report was provided to them and their signature on this form confirms receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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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