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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604688
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:27:26 PM

Document Has Been Signed on 12/17/2024 02:27 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:VILLA KALI MAFACILITY NUMBER:
374604688
ADMINISTRATOR/
DIRECTOR:		AMUNDSON, ASHLEYFACILITY TYPE:
772
ADDRESS:17676 VISTA RANCHO COURTTELEPHONE:
(760) 683-5152
CITY:RANCHO SANTA FESTATE: CAZIP CODE:
92067
CAPACITY: 6CENSUS: 5DATE:
12/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH: Operations Manager Elizabeth PowellTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analysts (LPAa) Hannah Rodgers and LPA Nacole Patterson conducted an unannounced Case Management visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Operations Manager Elizabeth Powell.

Today's visit was in response to a self-reported incident that occurred on 11/15/2024 regarding a medication error for Client #1 (C1). [See LIC811 Confidential Names List.]

During today’s visit LPAs reviewed facility records and interviewed relevant staff. No deficiencies were cited during today’s visit.

An exit interview was conducted with Operations Manger Powell, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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