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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604508
Report Date: 03/18/2024
Date Signed: 03/18/2024 01:53:11 PM


Document Has Been Signed on 03/18/2024 01:53 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:COGIR OF FALLBROOKFACILITY NUMBER:
374604508
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:1735 SO MISSION ROADTELEPHONE:
(760) 232-6800
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:128CENSUS: 0DATE:
03/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:ADMINISTRATOR, JESSICA ZEPEDATIME COMPLETED:
02:09 PM
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On March 18, 2024, Licensing Program Analyst (LPA), Venus Mixson made an unannounced visit for the purpose of the last facility's closure visit. LPA Mixson was greeted and granted entry by Administrator, Jessica Zepeda. LPA introduced herself and stated the purpose of the visit.

The LPA toured the facility along with the Administrator and made observations pertaining to the closure of the facility. There were no observable issues or concerns currently at the time of this visit.

The Licensee contacted Community Care Licensing on 02/01/2024, in reference to the closure of the facility. On todays date the Administrator, Jessica informed LPA Mixson that there were no residents living in the facility and accompanied the LPA on a tour of the facility.

The Licensee is initiating this closure. The effective date of closure currently is 03/17/2024, which was the day the final resident vacated the premises. LPA Mixson inspected the facility which included a sampling of the 103 living units to include, bathrooms, dining area, kitchen, and the inside and outside of the facility.
LPA Mixson confirmed there were no residents present, and there are no personal belongings for any resident, or staff currently at the time of this visit. The Administrator stated the reason for closure was the owner(s) filled bank.
The Administrator surrendered the original License (Effective Date: 04/22/2022). Facility Number 374604508, with a Total Capacity of 128.
An exit interview was conducted, and a copy of this report was discussed and provided to the Administrator, Jessica Zepeda.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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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