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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604667
Report Date: 05/26/2023
Date Signed: 06/01/2023 02:20:58 PM


Document Has Been Signed on 06/01/2023 02:20 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:MISSION VILLA WESTFACILITY NUMBER:
374604667
ADMINISTRATOR:ENGDAW, AMSAL D.FACILITY TYPE:
740
ADDRESS:2335 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 501-1244
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:6CENSUS: 5DATE:
05/26/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amsal D Engdaw- CEO/AdministratorTIME COMPLETED:
10:30 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Amsal D Engdaw- CEO/Administrator
Interview Method: Telephone interview

On May 26, 2023, Applicant/Administrator participated in COMP II for the below pending facilities: Mission Villa West/374604667 and Mission Villa East/374604668. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-Licensing Readiness
SUPERVISOR'S NAME: Tracy ThompsonTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Ricmar SorianoTELEPHONE: (916) 617-7083
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
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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