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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881394
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:45:29 PM

Document Has Been Signed on 10/10/2023 02:45 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DOLORE HOMEFACILITY NUMBER:
371881394
ADMINISTRATOR:ARACELI SONGCOFACILITY TYPE:
740
ADDRESS:1412 DOLORE PLACETELEPHONE:
(619) 717-1574
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 5DATE:
10/10/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Vicotria Baul - House ManagerTIME COMPLETED:
02:58 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced collateral visit to the facility regarding complaint 18-AS-20231002151526. LPA was granted entry and met with house manager Victoria Baul.

During the time of the visit, LPA conducted a walk through of the facility, reviewed facility documents and conducted interviews. No health or safety issues were observed during the time of the visit.

An exit interview was conducted and a copy of this report was discussed and provided to house manager Victoria Baul.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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