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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604734
Report Date: 08/01/2024
Date Signed: 08/01/2024 03:11:41 PM

Document Has Been Signed on 08/01/2024 03:11 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CHANGING OPTIONSFACILITY NUMBER:
374604734
ADMINISTRATOR/
DIRECTOR:		MELCHER, JENNIFERFACILITY TYPE:
735
ADDRESS:500 3RD STREETTELEPHONE:
(714) 224-0826
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 14CENSUS: 14DATE:
08/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Serita Polinaire, Clinical DirectorTIME VISIT/
INSPECTION COMPLETED:
02:30 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) Daniel Pena conducted an unannounced Case Management visit to deliver an amended LIC-9099 Complaint Investigation Report. LPA identified himself, was granted entry, and stated the purpose of the visit to Serita Polinaire, Clinical Director.

During the visit, LPA delivered an amended LIC-9099 which was previously delivered to the licensee's representative on June 19, 2024. No deficiencies were observed and no citations were issued as a result of observations made during today's visit.

An exit interview was conducted with Ms. Polinaire. A copy of this report and Licensee Appeal Rights (9058 03/22) were provided to Ms. Polinaire at the conclusion of the visit,
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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