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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603231
Report Date: 04/25/2024
Date Signed: 04/25/2024 10:50:07 AM

Document Has Been Signed on 04/25/2024 10:50 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BELMONT VILLAGE CARDIFFFACILITY NUMBER:
374603231
ADMINISTRATOR/
DIRECTOR:		ASHLEY MARCELLUSFACILITY TYPE:
740
ADDRESS:3535 MANCHESTER AVETELEPHONE:
(760) 436-8900
CITY:CARDIFF BY THE SEASTATE: CAZIP CODE:
92007
CAPACITY: 175CENSUS: DATE:
04/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Executive Director Wesley LavenderTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to correct/amend a report. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Wesley Lavender.

During today's visit, LPA formally amended a prior facility evaluation report and discussed the changes made with the Licensee. Licensee agreed to remove any copies of the prior report they have, substituting/replacing with the amended report.

No deficiencies were observed or cited during today’s visit.

An exit interview was conducted with Lavender, to whom a copy of the amended report, this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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