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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800558
Report Date: 04/21/2022
Date Signed: 04/21/2022 03:32:30 PM

Document Has Been Signed on 04/21/2022 03:32 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: 86DATE:
04/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jean NagleTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on multiple incident reports received by the Regional Office in October 2021 and December 2021. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Admissions Coordinator Jean Nagle. Resident Services Coordinator Carol Braun arrived during the visit.

During today's visit, LPA observed residents in care and interviewed staff.

No deficiencies were observed or cited on today's date. An exit interview was conducted with Resident Services Coordinator Carol Braun, to whom a copy of this report and the Licensee Rights (LIC9058 01/16) were provided via hardcopy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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