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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604290
Report Date: 10/20/2023
Date Signed: 10/20/2023 05:39:26 PM


Document Has Been Signed on 10/20/2023 05:39 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 - MAGNOLIASFACILITY NUMBER:
374604290
ADMINISTRATOR:WILLIAMS, DONELLEFACILITY TYPE:
740
ADDRESS:12735 MONTE VISTA RDTELEPHONE:
(858) 312-8469
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
10/20/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Erica Saade, Business Office ManagerTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced collateral visit to conduct a staff interview relative to investigations being conducted at two other licensed residential care facilities for the elderly. LPA introduced herself, disclosed the purpose of the visit, and was granted entry into the facility by Donna Tayag, Staff.

During the visit, LPA conducted an interview with a staff and observed residents in care.

No deficiencies were observed or cited during the visit.

An exit interview was conducted with Erica Saade, Business Office Manager, and copies of this report and Licensee Rights were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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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