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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 134604417
Report Date: 08/02/2023
Date Signed: 08/02/2023 09:35:12 PM

Document Has Been Signed on 08/02/2023 09:35 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SONRISA VILLA INC.FACILITY NUMBER:
134604417
ADMINISTRATOR:GUEVARA, ITZELFACILITY TYPE:
740
ADDRESS:708 E. 5TH ST.TELEPHONE:
(760) 756-3285
CITY:HOLTVILLESTATE: CAZIP CODE:
92250
CAPACITY: 175CENSUS: 99DATE:
08/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Gabriela "Gabby" Zamora, House ManagerTIME COMPLETED:
12:49 PM
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced case management visit. LPA was greeted and allowed entry by Fernanda Gonzalez, Medication Technician. LPA spoke to Gabriela "Gabby" Zamora, House Manager, to whom the purpose of the visit was disclosed to.

During today's visit, LPA briefly toured the facility, interviewed staff, and requested records. On July 31, 2023, Community Care Licensing received an incident report regarding Resident 1 (R1). The report stated that R1 passed away after going missing on July 28, 2023.

No deficiencies were issued today and no health or safety issues were identified. An exit interview was conducted with House Manager and a copy of this report, along with Licensee/Appeal Rights (LIC9058 03/22), were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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