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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604330
Report Date: 05/24/2022
Date Signed: 05/24/2022 05:56:37 PM

Document Has Been Signed on 05/24/2022 05:56 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
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: 30DATE:
05/24/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Joseph Baker, Assistant Program ManagerTIME COMPLETED:
12:42 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced Collateral Visit. LPA was granted entry into the facility by Joseph Baker, Assistant Program Manager, to whom she disclosed the purpose of the visit.

During today's visit, LPA interviewed a program participant in reference to a complaint lodged against another facility licensed by Community Care Licensing.

No deficiencies were cited during the visit.

This report was discussed with Joseph Baker. Copies of this report and Licensee/Appeal Rights were provided to the Assistant Program Manager at the conclusion of the visit, and his signature on this form acknowledges receipt of the rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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