Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701046
Report Date: 08/15/2017
Date Signed 08/15/2017 10:59:47 AM

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., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KIDS ON THE GOFACILITY NUMBER:
376701046
ADMINISTRATOR:EMLYN MARTINEZFACILITY TYPE:
840
ADDRESS:2015 BIRCH ROAD, UNIT 1703TELEPHONE:
(619) 407-7756
CITY:CHULA VISTASTATE: CAZIP CODE:
91915
CAPACITY:53CENSUS: 0DATE:
08/15/2017
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Destiny SzafarskiTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Iman Kayyali conducted an unannounced Case Management visit on this date. Upon arrival, LPA met Administrator Destiny Szafarski. There were no school age children present.

Purpose of today's visit is to provide and obtain signatures of electronic report for Annual Random inspection conducted on August 9, 2017. LPA was unable to obtain signatures or provide copies on day of inspection due to computer problems.

An exit interview was conducted. No deficiencies were observed or cited during today's visit.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Iman KayyaliTELEPHONE: (619) 767-2223
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2017
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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