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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604468
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:30:17 PM

Document Has Been Signed on 07/18/2023 04:30 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: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: 3DATE:
07/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Jeremiah LetuligasenoaTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Jeremiah Letuligasenoa.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/08/2023). The LIC624 described a medication incident involving Client #1 (C1). [See LIC 811 Confidential Names List for a description of C1.]

During today’s visit, LPA performed a brief facility tour and welfare check on clients in care, finding that all were safe. LPA also reviewed pertinent records and interviewed relevant staff.

No deficiencies were cited for the incident. Also, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with Letuligasenoa, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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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