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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604288
Report Date: 06/22/2022
Date Signed: 06/22/2022 09:47:49 PM


Document Has Been Signed on 06/22/2022 09:47 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:CADENCE AT POWAY GARDENS - THE PALMSFACILITY NUMBER:
374604288
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12708 MONTE VISTA RDTELEPHONE:
(858) 312-8492
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:24CENSUS: 14DATE:
06/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Donelle Williams, Executive DirectorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced case management visit. LPA was granted entry into the facility by Arwyne Morales, Care Partner, and met with Sherryl Anding, Resident Services Director, to whom she disclosed the purpose of the visit.

During today's visit, LPA toured the facility and interviewed the Resident Services Director in reference to an incident previously reported to Community Care Licensing.

No deficiencies were cited during the visit.

An exit interview was conducted with Donelle Williams, Executive Director, and copies of this report and Licensee/Appeal Rights were provided to the Executive Director at the conclusion of the visit. Her signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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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