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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604579
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:38:40 PM

Document Has Been Signed on 02/29/2024 02:38 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HEALING ADULT GROUP CARE INC.FACILITY NUMBER:
374604579
ADMINISTRATOR:SAIF, SALLYFACILITY TYPE:
735
ADDRESS:3919 EL CANTO DR.TELEPHONE:
(248) 307-6966
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 5DATE:
02/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Sally Saif, AdministratorTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA), Tiffany Holmes, conducted an unannounced Case Management visit to issue civil penalties based on complaint report issued on February 8, 2024. LPA met with Sally Saif, Administrator and was allowed entry into the facility after identifying herself and stating the purpose of the visit.

During the visit, civil penalties assessment was discussed with the Administrator. Based on the substantiated findings from the complaint report issued on February 8th, 2024, the Department determined that the violation of fire clearance resulted in an immediate civil penalty and it is being assessed in the amount of $500.00 for the date of 02/08/2024 and listed on the LIC421IM.

An exit interview was conducted and a copy of this report, LIC421IM, and Licensee/Appeals Rights (9058 01/16) were provided to the Administrator, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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