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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604290
Report Date: 03/26/2024
Date Signed: 03/26/2024 03:19:00 PM


Document Has Been Signed on 03/26/2024 03:19 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
SAN DIEGO RO, 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: 5DATE:
03/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Executive Director Donelle WilliamsTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted case management visit to amended a report to ED Williams. LPA identified herself and stated the purpose of the visit.

LPA informed the licensee of the reasons for the amended report and obtained signatures.

An exit interview was conducted with ED Williams. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to ED Williams. Signature below response confirms receipt of the documents.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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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