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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604686
Report Date: 06/19/2023
Date Signed: 06/19/2023 12:18:44 PM


Document Has Been Signed on 06/19/2023 12:18 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:4 PILLARS CARE LLCFACILITY NUMBER:
374604686
ADMINISTRATOR:MOALA, JOSHUAFACILITY TYPE:
735
ADDRESS:1641 CUYAMACA AVE.TELEPHONE:
(619) 834-9680
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 0DATE:
06/19/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Applicant's Representatives, Carson Spivey and Joshua MoalaTIME COMPLETED:
12:20 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 the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to Applicant's Representatives, Carson Spivey and Joshua Moala

During today’s visit, LPA, accompanied by the applicant's representatives, 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's representatives, 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: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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