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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800558
Report Date: 05/28/2021
Date Signed: 06/01/2021 02:39:28 PM

Document Has Been Signed on 06/01/2021 02:39 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:ST PAUL'S MANORFACILITY NUMBER:
370800558
ADMINISTRATOR:DAMIEN RAPPFACILITY TYPE:
740
ADDRESS:2635 SECOND AVETELEPHONE:
(619) 239-2097
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY: 200CENSUS: 96DATE:
05/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Director of Nursing Lisa CodinaTIME COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit to ensure confirmation of removal of S1 (see LIC 811 for confidential names). LPA Correia identified herself and met with the Director of Nursing Lisa Codina, and explained the purpose of the visit.

Director Codina confirmed with Human Resource Director Cory Fish that S1 was never an employee nor an applicant at the facility. A copy of the Decision and Order of Individual Exclusion (OIE) was emailed to the Director of Nursing for reference. No deficiencies were cited during today's visit.

An exit interview was conducted with Director of Nursing Lisa Codina, and a copy of this report along with the LIC 811, Licensee Rights (LIC 9058) and the OIE have been given for facility records via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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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