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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604637
Report Date: 05/12/2023
Date Signed: 11/07/2023 03:39:32 PM

Document Has Been Signed on 11/07/2023 03:39 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:BRAMBLEWOOD ARFFACILITY NUMBER:
374604637
ADMINISTRATOR:NOVAK, PARLARFACILITY TYPE:
735
ADDRESS:1261 PERSHING ROADTELEPHONE:
(619) 392-5802
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 6CENSUS: 5DATE:
05/12/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Licensee Novak TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Alyssa Ramirez met with licensee Novak. LPA had gone to the facility to conduct annual inspection but was informed by licensee that they just had their pre-licensing visit and were awaiting clearance from regional center in order to be able to move their clients to new location. Clients were offsite at day program during LPA's visits. LPA confirmed with LPM Telles that an annual inspection was not required at this time.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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