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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604323
Report Date: 03/30/2023
Date Signed: 03/30/2023 09:27:50 AM

Document Has Been Signed on 03/30/2023 09:27 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:SILVERGATE RANCHO BERNARDOFACILITY NUMBER:
374604323
ADMINISTRATOR:BRAKEVILLE, SONDRAFACILITY TYPE:
740
ADDRESS:16061 AVENIDA VENUSTOTELEPHONE:
(858) 451-1100
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 285CENSUS: 220DATE:
03/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maureen Manzon, Assistant Director of Resident Care, and Severino Doria, Director of Resident CareTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Carmen Lopez conducted a visit to the facility to deliver findings for an investigation and in conjunction conduct this case management visit. LPA identified herself and was granted entry by Mary Polka, Receptionist. LPA met with Maureen Manzon, Assistant Director of Resident Care, and Severino Doria, Director of Resident Care and disclosed the purpose of the visit.

LPA reviewed Title 22, Division 6, Chapter 8, Sections 87612 Restricted Health Conditions; and 87628 Diabetes. No deficiencies were cited during today’s visit.

An exit interview was conducted with Maureen Manzon, Assistant Director of Resident Care, and Severino Doria, Director of Resident Care and technical advisories were given per Title 22, Division 6, Chapter 8 of the California Code of Regulations. A copy of this report along with the Licensee Appeal Rights (LIC9058 03/22) were provided to Severino Doria, Director of Resident Care at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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