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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603746
Report Date: 03/07/2024
Date Signed: 03/18/2024 04:39:23 PM

Document Has Been Signed on 03/18/2024 04:39 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:CHHINA'S SENIOR GUEST HOUSEFACILITY NUMBER:
374603746
ADMINISTRATOR:CHHINA, JIWAN SFACILITY TYPE:
740
ADDRESS:8632 SPRING VISTA WAYTELEPHONE:
(619) 337-5201
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 5DATE:
03/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee ChhinaTIME COMPLETED:
10:40 AM
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Licensing Program Analysts (LPAs) Debbie Correia and Daniel Pena conducted an unannounced visit to obtain signatures on an amended report. During today’s visit, LPAs were greeted by Caregiver Maria Marks identified themselves and met with Licensee Chhina and discussed the purpose of the visit.

During today’s visit, LPAs 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, whose signature below confirms receipt of a copy of this report the (LIC 809) and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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