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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
374602940
Report Date:
04/13/2022
Date Signed:
05/23/2022 04:24:38 PM
Document Has Been Signed on
05/23/2022 04:24 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 II
FACILITY NUMBER:
374602940
ADMINISTRATOR:
WILFREDO SALAZAR
FACILITY TYPE:
740
ADDRESS:
566 PARKWOOD DRIVE
TELEPHONE:
(619) 944-3018
CITY:
SAN DIEGO
STATE:
CA
ZIP CODE:
92139
CAPACITY:
6
CENSUS:
5
DATE:
04/13/2022
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME BEGAN:
10:10 AM
MET WITH:
Caregiver Joy Singson
TIME COMPLETED:
11:00 AM
NARRATIVE
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This is an amended version of the original report left at the facility on 04/13/2022. This report was created in error.
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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