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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604505
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:29:40 PM


Document Has Been Signed on 01/31/2024 04:29 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:UC SENIOR CARE IVFACILITY NUMBER:
374604505
ADMINISTRATOR:DEREK POSADAFACILITY TYPE:
740
ADDRESS:3810 GOVERNOR DRIVETELEPHONE:
(858) 583-6431
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 6DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Caregivers Raquel Jimenez and Oscar Bojorquez TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. The LPA introduced himself and disclosed the purpose of the visit to Caregivers Raquel Jimenez and Oscar Bojoquez.

During today’s visit, The LPA toured the facility, reviewed the facility food supply and stored medication. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection.

An exit interview was conducted with Caregiver Jimenez, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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