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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604545
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:28:18 PM


Document Has Been Signed on 09/15/2022 02:28 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:GARDENS AT ESCONDIDOFACILITY NUMBER:
374604545
ADMINISTRATOR:MACATANGAY, TINAFACILITY TYPE:
740
ADDRESS:1342 NORTH ESCONDIDO BLVDTELEPHONE:
(760) 480-8155
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:101CENSUS: 60DATE:
09/15/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amy Banaga TIME COMPLETED:
10:30 AM
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
COMP II by CAB successfully completed


Facility Type: RCFE
Application Type: LLC
Capacity: 101
Census (if any clients in care): 60
Method: Telephone at CAB
COMP II Participants: Amy Banaga (Administrator/Applicant's Representative)

Applicant/Administrator participated in COMP II at CAB via telephone with analyst at CAB. Identification of the Applicant and Administrator was verified by providing California Driver License number. During COMP II, Applicant and Administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program


2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting
incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance,
Health screening, Fire clearance, First Aid/CPR certificate, Administrator
certificate, Financial verification, Pre-licensing inspection, Compliance history,
Control of property
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Thai DoanTELEPHONE: (916) 651-1057
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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