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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601334
Report Date: 05/23/2022
Date Signed: 05/23/2022 01:10:20 PM

Document Has Been Signed on 05/23/2022 01:10 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:SERRA MESA GUESTS HOME III, LLCFACILITY NUMBER:
374601334
ADMINISTRATOR:SALAZAR, EVELYNFACILITY TYPE:
740
ADDRESS:3008 MELBOURNE DRTELEPHONE:
(858) 277-6515
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 6CENSUS: 6DATE:
05/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Administrator Evelyn SalazarTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Kayla Hilario, conducted an unannounced case management visit to amend a report that was created on 04/13/2022. LPA identified herself, discussed the purpose of the visit and met with Administrator Evelyn Salazar.

During the visit, LPA explained the amended 809 Facility Visit Report. An exit interview was conducted with Administrator Evelyn Salazar. The amended report, Licensee Rights (LIC 9058 01/16), and a copy of this report was provided to via hardcopy at the conclusion of the visit.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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