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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604289
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:45:08 PM


Document Has Been Signed on 10/26/2023 04:45 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:POWAY GARDENS SENIOR LIVING - MOUNTAIN VISTASFACILITY NUMBER:
374604289
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12695 MONTE VISTA RDTELEPHONE:
(858) 312-5406
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:32CENSUS: 8DATE:
10/26/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Donelle Williams, Executive DirectorTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced Collateral Visit. LPA was granted entry into the facility and met with Donelle Williams, Executive Director, to whom LPA disclosed the purpose of the visit.

During today's visit, LPA interviewed staff in reference to a complaint lodged against another facility licensed by Community Care Licensing.

No deficiencies were cited during the visit.

This report was reviewed with Donelle Williams, and copies of the report and Licensee/Appeal Rights were provided to the Executive Director at the conclusion of the visit. Her signature on the report acknowledges receipt of copies of the the rights and report.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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