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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604481
Report Date: 07/25/2023
Date Signed: 07/25/2023 12:23:50 PM

Document Has Been Signed on 07/25/2023 12:23 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:COLUMBIA RESIDENTIAL CARE LLCFACILITY NUMBER:
374604481
ADMINISTRATOR:CHANEL BERNARTEFACILITY TYPE:
735
ADDRESS:1610 COLUMBIA STREETTELEPHONE:
(858) 294-3670
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 4CENSUS: 3DATE:
07/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Cody SmithTIME COMPLETED:
12:32 PM
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Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Case Management Visit regarding a previous incident. The facility file was reviewed prior to the visit. LPA met with Caregiver Cody Smith and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside. Two clients were present during the visit.

No deficiencies were cited or observed on this date.

An exit interview was conducted with Cody Smith. A copy of this report along with Licensee Rights was provided to Cody Smith whose signature below verifies receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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