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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604330
Report Date: 09/13/2023
Date Signed: 09/13/2023 01:40:21 PM

Document Has Been Signed on 09/13/2023 01:40 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: 33DATE:
09/13/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shanta Haines, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced collateral visit to conduct a client interview relative to a licensed adult residential facility. LPA introduced herself, disclosed the purpose of the visit, and was granted entry into the facility.

During the visit, LPA conducted an interview with a program consumer who resides in an Adult Residential Facility licensed by Community Care Licensing.

No deficiencies were observed or cited during the visit.

An exit interview was conducted with Shanta Haines, Administrator, and copies of this report and Licensee Rights were provided to the administrator at the conclusion of the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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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