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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604331
Report Date: 02/21/2023
Date Signed: 02/21/2023 02:32:01 PM

Document Has Been Signed on 02/21/2023 02:32 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:MARANATHA DAY PROGRAMFACILITY NUMBER:
374604331
ADMINISTRATOR:GUIBERT, NICOLEFACILITY TYPE:
775
ADDRESS:1112 BROADWAY, #103TELEPHONE:
(619) 760-3322
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 45CENSUS: DATE:
02/21/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Stephanie Bagley, Direct Support Personnel IIITIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced collateral visit to the day program to conduct interviews. LPA Lopez identified herself and stated the purpose of the visit with Cindy Pedrero, Staff Leader.

During the visit, LPA Lopez interviewed staff #1 (S1) and staff #2 (S2) (See LIC811 Confidential Names list) and requested and obtained relevant documents. No deficiencies were observed during today's visit.

An exit interview was conducted, and a copy of this report, an LIC811 Confidential Names list, along with Licensee/Appeal Rights (LIC9058 03/22) was provided to Stephanie Bagley, Direct Support Personnel III at the conclusion of the visit. The signature below confirms the receipt of the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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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