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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604487
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:15:01 PM

Document Has Been Signed on 10/14/2021 03:15 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:SPARKS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
374604487
ADMINISTRATOR:SPARKS, ELSIEFACILITY TYPE:
735
ADDRESS:1973 LIEDER DR.TELEPHONE:
(619) 896-1865
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY: 6CENSUS: DATE:
10/14/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Elsie SparksTIME COMPLETED:
02:50 PM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care):
Method: Telephone call with CAB
COMP II Participants: Elsie Sparks

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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