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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800930
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:34:13 PM

Document Has Been Signed on 02/02/2023 03:34 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 MADELEINE SOPHIES CENTERFACILITY NUMBER:
370800930
ADMINISTRATOR:DEBRA EMERSONFACILITY TYPE:
775
ADDRESS:2119 E. MADISON AVENUETELEPHONE:
(619) 442-5129
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 400CENSUS: 370DATE:
02/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Program Director Thomas Carr and Program Manager Kara GonzalesTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on events which licensee self-reported to the Community Care Licensing San Diego Regional Office (RO). LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Program Director Thomas Carr and Program Manager Kara Gonzales.

On 02-02-2023, the RO received an LIC624 Unusual Incident Report which said during an outdoor hiking activity on 01-25-2023 chaperoned by Staff #1 (S1), Client #1 (C1) became separated from the group and was missing for “at least 30 minutes.” [See LIC811 Confidential Names List for identification of S1 and C1]. Law enforcement subsequently located C1 and returned them uninjured to staff.

During today’s visit, LPA briefly toured the day program’s facility, performed a welfare check on clients in care, obtained pertinent records, and interviewed C1 and relevant staff. LPA visually verified C1 was unharmed. At the present time, the incident requires further investigation. Possible follow-up telephone calls and/or visits are necessary before a determination of investigation findings can be made.

An exit interview was conducted with Carr and Gonzales, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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