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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604468
Report Date: 09/24/2021
Date Signed: 09/24/2021 11:24:12 AM

Document Has Been Signed on 09/24/2021 11:24 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:TRANSFORMED LIVING HOMESFACILITY NUMBER:
374604468
ADMINISTRATOR:GONZALEZ JR, EDUARDOFACILITY TYPE:
735
ADDRESS:1311 GRAND AVETELEPHONE:
(619) 990-8870
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 0DATE:
09/24/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:15 PM
MET WITH:Yarinn Gonzalez, Administrator &
Eduardo Gonazlaez APplicant		TIME COMPLETED:
10:45 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. LPA met Administrator and was granted entry by Yarinn Gonzalez.

During today's visit, LPA, accompanied Yarinn and Eduardo via Facetime toured the facility inside and outside and inspected every room. The facility was found to be in good repair with no pathway obstructions. Clients' bedrooms were observed to be clean and contained required furnishings. Toilets were found to be in working order. Facility temperature was 70 degrees F during the visit. Water temperature in bathroom to be used by clients measured at 117 degrees F. There are locked cabinets for storage of medications and client and staff records. There was a first aid kit present in the facility. Activities and sufficient space in which to conduct activities are present. A fire extinguishers was observed in the facility. Smoke and carbon monoxide detectors were tested and found to be in working order. No pools or bodies of water were observed near or on the premises. According to the applicant, no firearms and/or ammunition are present or will be stored in the facility. Sufficient and appropriate storage was present to store perishable and non-perishable food items. Non-perishable food items were present for future client use. Required postings were observed in visible areas of the facility.

Items reviewed during today's visit are in compliance with Title 22, Division 6, Chapter 8 of California Code of Regulations, and applicant has passed the pre-licensing inspection. Component III was completed during today’s visit. Eduardo and Yarinn was advised that the application is pending management final review and approval. This report was discussed with the applicant, and a copy of the report and Applicant Rights (LIC 9058) were provided to Eduardo via email at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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