<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604481
Report Date: 12/03/2024
Date Signed: 12/04/2024 07:39:19 AM

Document Has Been Signed on 12/04/2024 07:39 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COLUMBIA RESIDENTIAL CARE LLCFACILITY NUMBER:
374604481
ADMINISTRATOR/
DIRECTOR:		CHANEL BERNARTEFACILITY TYPE:
735
ADDRESS:1610 COLUMBIA STREETTELEPHONE:
(858) 294-3670
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 4CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Chanel BernarteTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management visit. LPA was welcomed by Caregiver Malia Knaki . LPA met with Administrator Chanel Bernarte and discussed the the complaint.

Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report. On 11/1/2024 the facility reported an AWOL of Client#1 (C1 – See LIC811 Confidential Names List for identification of C1). Review of records revealed that C1 is able to leave the facility unassisted. C1 returned to the facility the same day. Absentee notification plan was followed.

LPA briefly toured the facility, performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date.

An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with Licensee, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1