<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604534
Report Date: 04/27/2022
Date Signed: 04/27/2022 02:53:16 PM

Document Has Been Signed on 04/27/2022 02:53 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:SJIC II - HOME & CAREFACILITY NUMBER:
374604534
ADMINISTRATOR:KAIRUZ-RASHDI, MARIAFACILITY TYPE:
735
ADDRESS:1125 FOXBORO AVETELEPHONE:
(619) 216-0019
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: DATE:
04/27/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Lino Macaraeg, Jr.-Licensee; Caroline Macaraeg-Licensee; Maria Kairuz Rashdi-AdministratorTIME COMPLETED:
02:47 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Facility Type: ARF
Application Type: CHOW
Capacity: 4
Census: 4
COMP II Participants: Lino Macaraeg, Jr.-Licensee; Caroline Macaraeg-Licensee; Maria Kairuz Rashdi-Administrator
Interview Method: Telephone interview

On 4/27/22, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1