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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604483
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:44:12 PM

Document Has Been Signed on 02/20/2025 03:44 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:SHORESIDE VILLA ASSISTED LIVINGFACILITY NUMBER:
374604483
ADMINISTRATOR/
DIRECTOR:		KAHNIS, KEVINFACILITY TYPE:
740
ADDRESS:1911 S FREEMAN STTELEPHONE:
(442) 266-2107
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 3CENSUS: 3DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Caregiver Mina RajabiTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Mina Rajabi. LPA spoke with Administrator Quetzalli "Sally" Kahnis via telephone during the visit.

During today's visit, LPA accompanied by Caregiver Rajabi toured the facility, reviewed facility records, and observed residents in care. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed.

No deficiencies were cited on today's date. An exit interview was conducted with Caregiver Rajabi, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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