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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601185
Report Date: 08/25/2023
Date Signed: 08/25/2023 11:13:17 AM

Document Has Been Signed on 08/25/2023 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SERRA MESA GUESTS HOME, LLCFACILITY NUMBER:
374601185
ADMINISTRATOR:EVELYN MAGNO SALAZARFACILITY TYPE:
740
ADDRESS:8693 CELESTINE AVENUETELEPHONE:
(858) 576-9701
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 6CENSUS: 5DATE:
08/25/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:55 PM
MET WITH:Evelyn Salazar, LicenseeTIME COMPLETED:
10:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) visit to confirm that a citation which was issued on 08/22/2023 has been corrected.

LPA identified himself to, and discussed the purpose of the visit with Caregiver, Alma Lim. Licensee, Evelyn Salazar arrived and LPA explained the purpose with her. LPA conducted a health and safety check and observed the five (5) residents present on the day of the visit.

The following citation was reviewed during today's visit:

80068.5 Eviction Procedures. On 08/23/2023, Licensee E-mailed LPA to inform him that the facility had contracted with an outside training provider to present Personal Rights and Eviction Procedures training, meeting the POC deadline. On 08/25/2023, LPA reviewed the vendor invoice and contract, finding them satisfactory. LPA provided Licensee, Salazar a copy of the POC Clearance Letter.

No new deficiencies were identified or cited during today's visit.

An exit interview was conducted with Ms. Salazar to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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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