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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604343
Report Date: 07/09/2024
Date Signed: 07/09/2024 01:48:12 PM


Document Has Been Signed on 07/09/2024 01:48 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:CARABELLE SENIORS HOMEFACILITY NUMBER:
374604343
ADMINISTRATOR:DIO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:920 SACRAMENTO AVE.TELEPHONE:
(619) 713-1137
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 0DATE:
07/09/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Josephine Dio, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an announced case management visit regarding facility closure. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Josephine Dio, Administrator

In April of 2024. they advised LPA Holmes they were going to start the closure process. Per the licensee, all three (3) clients were located to a new location. All of the residents have been relocated as of July 1, 2024. LPA has called the new facilities and confirmed the location of the residents and the move in dates.

During today's visit, LPA briefly toured the facility location, verifying that there were no residents present and that facility operations have ceased there. All resident clothing and personal effects have been relocated. All staff, resident files and licensing postings have been relocated. The administrator provided LPA with the license during the visit.

No deficiencies were issued, and the facility's location is ready for closure.

An exit interview was conducted with Josephine Dio, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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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