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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604330
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:49:49 PM

Document Has Been Signed on 09/29/2022 12:49 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:AMARIS CENTER FOR CHANGEFACILITY NUMBER:
374604330
ADMINISTRATOR:GASQUE, RUKHSANAFACILITY TYPE:
775
ADDRESS:250 E DOUGLAS AVETELEPHONE:
(202) 520-3781
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 40CENSUS: 28DATE:
09/29/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rukhsana Gasque, LicenseeTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Vicky Williamson, and County of San Diego Nurse Sandra Brackman, conducted an on-site visit. LPA and Nurse identified themselves and discussed the purpose of the visit with Licensee Rukhsana Gasque.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, screening protocols as well as the use of personal protective equipment. During today's visit, Rukhsana Gasque, was interviewed and a walk-though of the facility was conducted. A debriefing was conducted with Licensee Rukhsana Gasque, at the conclusion of the visit.

No deficiencies were issued today. An exit interview was conducted with Rukhsana Gasque, Licensee and a copy of this report, along with the Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Licensee.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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