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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603746
Report Date: 02/29/2024
Date Signed: 04/15/2024 07:56:44 PM

Document Has Been Signed on 04/15/2024 07:56 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CHHINA'S SENIOR GUEST HOUSEFACILITY NUMBER:
374603746
ADMINISTRATOR/
DIRECTOR:		CHHINA, JIWAN SFACILITY TYPE:
740
ADDRESS:8632 SPRING VISTA WAYTELEPHONE:
(619) 337-5201
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 5DATE:
02/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee Jiwan (Jay) ChhinaTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to obtain signatures on an amended report. During today’s visit, LPA was greeted by the Licensee, identified herself and met with and discussed the purpose of the visit.

During today’s visit, LPA obtained Licensee's signature on an amended version of a report originally delivered on February 27, 2024.

An exit interview was conducted with Licensee Chhina and a copy of this report and the Licensee Appeal Rights (LIC 9058 3/22) were provided.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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