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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604690
Report Date: 09/20/2023
Date Signed: 09/20/2023 10:59:43 AM


Document Has Been Signed on 09/20/2023 10:59 AM - 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:CARROLL'S RESIDENTIAL CAREFACILITY NUMBER:
374604690
ADMINISTRATOR:MEYERS, BRYANFACILITY TYPE:
740
ADDRESS:655 S MOLLISON AVETELEPHONE:
(619) 444-3181
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:144CENSUS: 125DATE:
09/20/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Bryan MeyersTIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA), Ramon Serrano, conducted an unannounced collateral visit as a follow-up for an unrelated complaint investigation for another facility. LPA was allowed entry by Administrator Bryan Meyers and discussed the purpose of the visit.

During the visit, LPA conducted interviews with residents and staff and obtained facility records.

An exit interview was conducted with Bryan Meyers and copy of this report along with Licensee Rights was provided to Bryan Meyers whose signature below verifies receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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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