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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604614
Report Date: 02/06/2023
Date Signed: 02/06/2023 03:50:16 PM


Document Has Been Signed on 02/06/2023 03:50 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:ANABELLAHOMECAREFACILITY NUMBER:
374604614
ADMINISTRATOR:CHERRY COOKFACILITY TYPE:
740
ADDRESS:14249 HIGH VALLEYTELEPHONE:
(406) 998-8022
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 0DATE:
02/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Applicant Cherry CookTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified themselves to, and explained the purpose of the visit to applicant Cherry Cook.


The facility fire clearance was granted on 09-20-2022 and reflects that the facility was approved for six residents in total, of which five (5) may be non-ambulatory and one (1) may be bedridden.

During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. There are items which must be corrected for the facility to comply with regulation(s). The applicant did not pass the pre-licensing inspection, and a return visit will be required.

An exit interview was conducted with the applicant, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
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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