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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604515
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:10:19 PM

Document Has Been Signed on 12/15/2021 04:10 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:INGLESIDE HOUSEFACILITY NUMBER:
374604515
ADMINISTRATOR:CROCKER, CHRISTINAFACILITY TYPE:
735
ADDRESS:3707 VIA CIELO AZULTELEPHONE:
(619) 277-2016
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY: 4CENSUS: 0DATE:
12/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Christina CrockerTIME COMPLETED:
04:32 PM
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Licensing Program Analyst (LPA) Kennedy conducted a Prelicensing/Component III Visit to observe the physical plant for compliance. The LPA was met and granted entry into the facility by Christina and Ward Crocker, applicants. The LPA and the applicants toured the physical plant and observed by the LPA were resident accommodations including furnishings, linens and personal hygiene items; resident bathroom is equipped with non-skid flooring and water temperature read 112 F; resident, staff, and facility records are located in a locked file cabinet in the office area of the house; food service including dishes, utensils, food storage and a seven day supply of nonperishables and a two day supply of fresh perishables are present; toxic substances are stored locked in the laundry room and in a locked cabinet in the kitchen; medication storage and administration logs are located in locked closet; first aid kit and first aid manual are located in the medication closet; activities, supplies and sufficient space to conduct are present; smoke and carbon monoxide detectors are present and operable; facility posting requirements are present in a common area and the facility administrator's certification is current; a pool is is present at the facility and a fence surrounding the pool is present that meets the required regulations; there are guns and ammunition located on the property. The guns are locked in a gun safe and the ammunition is stored in a locked box separate from the guns. Discussed with the applicants were continuing operation requirements, record keeping and physical plant compliance. The applicant shall contact the Centralized Application Unit (CAU) for completion of this pending facility application.

An exit interview was conducted with Christina and Ward Crocker, applicants. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to Ms. Crocker via email. An electronic response confirms the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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