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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604330
Report Date: 08/24/2023
Date Signed: 08/24/2023 11:01:58 AM

Document Has Been Signed on 08/24/2023 11:01 AM - 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: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: 29DATE:
08/24/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Shanta Haines, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced collateral visit to the facility to conduct staff interviews. LPA Lopez identified herself and was granted entry by Joseph Baker, Program Manager. LPA Lopez stated the purpose of the visit with Shanta Haines, Administrator.

During the visit, LPA Lopez interviewed staff members, and requested and obtained relevant records. No deficiencies were observed during today's visit.

An exit interview was conducted, and a copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) wereprovided to Administrator Haines, at the conclusion of the visit. The signature below confirms the receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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