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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604320
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:56:58 PM


Document Has Been Signed on 08/24/2022 03:56 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SAMUEL TAYLOR HOMES LLC.FACILITY NUMBER:
374604320
ADMINISTRATOR:AMBEBA, CHRIS LUMULIFACILITY TYPE:
735
ADDRESS:5081 REYNOLDS STREETTELEPHONE:
(619) 310-6973
CITY:SAN DIEGOSTATE: CAZIP CODE:
92113
CAPACITY:4CENSUS: 3DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator Chris AmbebaTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Manager (LPM) John Rante and Licensing Program Analyst (LPA) Riza Alvarez, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPM and LPA met with Administrator Chris Ambeba, and we discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPM and LPA conducted a tour of the facility, both inside and outside and observed the clients in care. In accordance with the Department’s Infection Control, LPM and LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

The Licensee will be provided a copy of their appeal rights (LIC9058 03/22). An exit interview was conducted and a copy of this report was provided to the Administrator, along with their appeal rights
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Riza Gloria AlvarezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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