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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604761
Report Date: 05/07/2024
Date Signed: 05/07/2024 12:41:24 PM


Document Has Been Signed on 05/07/2024 12:41 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:CASA ABUELA'SFACILITY NUMBER:
374604761
ADMINISTRATOR:GUTIERREZ, MARY ANNFACILITY TYPE:
740
ADDRESS:194 H STREETTELEPHONE:
(619) 240-3866
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: 0DATE:
05/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Mary Ann GutierrezTIME COMPLETED:
12:53 PM
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management visit to inspect the facility for an increase in bedridden capacity from zero (0) to one (1). LPA was greeted at the front door by Administrator Mary Ann Gutierrez and granted entry after identifying himself and disclosing the purpose of his visit.

On May 1, 2024 the Fire Department approved one (1) bedridden resident in bedroom #4. During today's visit, LPA briefly toured the facility to include bedridden bedroom #4. No deficiencies were observed today.

This portion of the application process is complete, and will be forwarded to management for final review and approval. The Administrator will then be notified of management approval by phone or email and the new license will be mailed to the Licensee.

An exit interview was conducted with Mary Ann Gutierrez and a copy of this report along with licensee rights was provided. Signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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