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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604801
Report Date: 02/19/2026
Date Signed: 02/19/2026 03:18:48 PM

Document Has Been Signed on 02/19/2026 03:18 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:CAVELARIS COMMUNITY CAREFACILITY NUMBER:
374604801
ADMINISTRATOR/
DIRECTOR:		MERZIOTIS, MARGAUXFACILITY TYPE:
735
ADDRESS:9975 SAN JUAN STTELEPHONE:
(619) 370-6733
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 22CENSUS: 22DATE:
02/19/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Arlene Doulopoulos AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Tiffany Holmes, conducted an unannounced Case Management visit to issue civil penalties based on complaint report issued on February 12, 2026. LPA met with Arlene Doulopoulos Administrator and was allowed entry into the facility after identifying herself and stating the purpose of the visit.

During the visit, civil penalties assessment was discussed with the Arlene Doulopoulos Administrator. Based on the substantiated findings from the complaint report issued on February 12th, 2026, the Department determined that the violation of same deficiency cited in the same year required an immediate civil penalty and it is being assessed in the amount of $1000. Civil Penalty listed on the LIC421IM.

During another visit on 02/13/2026 another civil penalty is being assessed in the amount of $2000 for 4 staff not being associated to the facility. LPA is citing for non fingerprinted staff on this case management.
Civil Penalty listed on the LIC421BG- CPA for $500 for 5 days for 4 staff. S1, S2, S3 & S4 ** Please see attached LIC 811 confidential names list**
The department also received an incident report on 02/28/2026 regarding an overdose at the facility for the same client that overdosed last week. The client was using drugs and interviews revealed emergency services (911) were called and arrived on the scene shortly after and administered Narcan to C1. The client went to the hospital on 02/12/2026. Interviews revealed the staff do rounds to check on the clients activity and safety. Interviews revealed that they plan to increase staff monitoring of the rooms, provide more staff training on signs of drug usage and reinforce the house rules that possession of illicit drugs is prohibited.
An exit interview was conducted and a copy of this report, LIC421IM, and LIC421BG CPA Licensee/Appeals Rights (9058 03/22) were provided to the Administrator, whose signature on this form confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Tiffany Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/19/2026 03:18 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 02/18/2026 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CAVELARIS COMMUNITY CARE
FACILITY NUMBER: 374604801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2026
Section Cited
CCR
80019(e)(1)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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Licensee will not have staff work or be present in the facility until fingerprint cleared and associated. Licensee stated she will provide proof of fingerprint clearance by POC due date of 02/27/2026
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Based on record review the licensee did not ensure all staff were fingerprint cleared for 3 out of 3 staff [S1, S2, S3, S4] which poses an immediate health, safety and personal rights to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Tiffany Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
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