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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604444
Report Date: 03/03/2023
Date Signed: 03/03/2023 09:59:07 AM


Document Has Been Signed on 03/03/2023 09:59 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SEA DRAGON FOUNDATION INDEPENDENT RESIDENTIALFACILITY NUMBER:
374604444
ADMINISTRATOR:LE,BONG LAI (LUCIE)FACILITY TYPE:
740
ADDRESS:5711 BOUNTY STREETTELEPHONE:
(619) 916-6114
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:6CENSUS: 6DATE:
03/03/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Elsie GonzalezTIME COMPLETED:
10:09 AM
NARRATIVE
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Licensing Program Analyst (LPA), Ramon Serrano, conducted an unannounced collateral visit as a follow-up for an unrelated complaint investigation for another facility. LPA was allowed entry by Caregiver Elsie Gonzalez and discussed the purpose of the visit.

During the visit, LPA interviewed a resident in care and obtained facility records.

An exit interview was conducted with Elsie Gonzalez and a copy of this report along with Licensee Rights (LIC 9058 3/22) was provided to Elsie Gonzalez whose signature below verifies receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
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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