<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604668
Report Date: 06/23/2023
Date Signed: 06/23/2023 12:26:41 PM


Document Has Been Signed on 06/23/2023 12:26 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:MISSION VILLA EASTFACILITY NUMBER:
374604668
ADMINISTRATOR:ENGDAW, AMSALFACILITY TYPE:
740
ADDRESS:2337 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 501-1788
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:6CENSUS: 3DATE:
06/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant Amsel EngdawTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified themselves to, and explained the purpose of the visit to Applicant Amsel Engdaw.

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 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1