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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604559
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:12:37 PM

Document Has Been Signed on 04/18/2024 03:12 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ROSE'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
374604559
ADMINISTRATOR/
DIRECTOR:		SAMORA, YVONNEFACILITY TYPE:
735
ADDRESS:1386 STANISLAUS DRIVETELEPHONE:
(619) 349-3953
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 4CENSUS: 3DATE:
04/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Licensee Yvonne SamoraTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an case management visit due to a request to change the facility capacity. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Licensee Yvonne Samora.

A Change of Capacity application was received by the Department on March 12, 2024, in which the licensee requested an increase in ambulatory capacity from 4 to 6 residents. The Fire Safety Inspection Request was approved by the local fire authority on April 10, 2024.

During today’s visit, LPA toured the facility and inspected each room. The facility sketch was consistent with the current layout of the facility. No immediate health and/or safety concerns were observed during today's visit.

The completed change of capacity request will be forwarded to management for final review and approval. An exit interview was conducted with Licensee, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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