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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602940
Report Date: 05/23/2022
Date Signed: 05/23/2022 04:19:54 PM

Document Has Been Signed on 05/23/2022 04:19 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 IIFACILITY NUMBER:
374602940
ADMINISTRATOR:WILFREDO SALAZARFACILITY TYPE:
740
ADDRESS:566 PARKWOOD DRIVETELEPHONE:
(619) 944-3018
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 6CENSUS: 3DATE:
05/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:House Manager Evelyn Salazar. TIME COMPLETED:
04:30 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 House Manager Evelyn Salazar.

During the visit, LPA explained the amended 809 Facility Visit Report. No health or safety issues were identified. An exit interview was conducted with House Manager Evelyn Salazar. The amended report, a copy of this report, and Licensee Rights (LIC 9058 01/16) were 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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