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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004506
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:01:29 PM

Document Has Been Signed on 06/02/2022 01:01 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:CARPEL BOARD & CARE FACILITY #2FACILITY NUMBER:
372004506
ADMINISTRATOR:CARMONA, LEONOR P.FACILITY TYPE:
740
ADDRESS:2091 HANFORD DRIVETELEPHONE:
(858) 569-1691
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY: 6CENSUS: 6DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Leonor CarmonaTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to provide consultation with the Licensee during a complaint investigation visit which occurred on 6/2/2022. LPA was greeted by, identified herself to, and explained the purpose of the visit to Licensee Leonor Carmona.

During the visit, LPA observed the residents in care, provided guidance, and reviewed forms with the Licensee.

An exit interview was conducted with Licensee Leonor Carmona, to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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