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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800394
Report Date: 05/18/2021
Date Signed: 05/18/2021 10:07:46 AM

Document Has Been Signed on 05/18/2021 10:07 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:COVENANT LIVING AT MOUNT MIGUELFACILITY NUMBER:
370800394
ADMINISTRATOR:RICHARD MILLERFACILITY TYPE:
741
ADDRESS:325 KEMPTON STREETTELEPHONE:
(619) 479-4790
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 434CENSUS: 335DATE:
05/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ron Alamario, Assisted Living
Director		TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced case management visit to follow up on an incident report received on 05/13/2021 regarding an attempted suicide. LPA met with Ron Almario, Assisted Living Director and explained the reason for this visit.

During today's visit, LPA spoke with AL Director regarding the incident. Fran Lacangan the Clinic Manager arrived during the visit.

The incident report dated 05/12/2021, where resident 1 (R1) attempted to take a bottle of Melatonin. R1 told a neighbor that they took the bottle of pills and that they didn't even fall asleep. The neighbor took R1 to their spouse and they reported the incident to Fran the Clinic Manager. The spouse made an appointment the with the therapist the same day. After the appointment they didn't keep R1 so the spouse took R1 to the emergency room on 05/12/2021- 05/14/2021. R1 was released in the evening of 05/14/2021 back to the facility. The hospital ordered home health for R1.

There were no deficiencies observed during the visit.

An exit interview was conducted with Ron Almario, Assisted Living Director and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) was emailed to Ron via email; an email read receipt confirms receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2021
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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