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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604686
Report Date: 09/19/2024
Date Signed: 09/19/2024 12:45:59 PM


Document Has Been Signed on 09/19/2024 12:45 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
SAN DIEGO RO, 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: 4DATE:
09/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Joshua Moala, AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analysts (LPAs), Tiffany Holmes and Renita Hall conducted an unannounced case management visit. LPA Holmes introduced herself and explained the purpose of the visit to Joshua Moala, Administrator

Today’s visit was regarding incident reports received on 09/09/2024 and 09/18/2024 in the office. During today’s visit LPAs did not tour the facility inside due to client having a behavior. LPA's stood outside and conducted the visit with Licensee.

LPA Holmes conducted interviews with staff. Staff interviews revealed the incidents both involved Client 1(C1) and Client 2 (C2). Interviews revealed that PERT comes each time they are called. Interviews revealed that they determine which hospital the client will go to. The licensee took C1 for a ride and when they stopped and was ordering food C1 attacked the licensee. C1 went to the hospital on Saturday and returned Monday. The facility has a verbal plan in place and they put the protocol in shift notes. C1 was given a 30 day notice on September 16, 2024 due to needing a higher level of care.

Based on todays visit, no deficiencies were observed or cited during todays visit

An exit interview was conducted with Joshua Moala, Administrator. A copy of this report, and the Licensee/Appeal Rights (9058 03/22) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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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