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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370802865
Report Date: 09/16/2021
Date Signed: 09/17/2021 08:18:20 AM

Document Has Been Signed on 09/17/2021 08:18 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:ORLANDO GUEST HOMEFACILITY NUMBER:
370802865
ADMINISTRATOR:CYRALYNN MABALOTFACILITY TYPE:
735
ADDRESS:297 -299 ORLANDOTELEPHONE:
(619) 444-9411
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 34CENSUS: 34DATE:
09/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Fe MartinezTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced Case Management inspection regarding a client death submitted to the San Diego office on September 15, 2021. LPA met with Administrator, Fe Martinez, and was allowed entry into the facility after identifying himself and stating the purpose of the visit.

It was reported that Client #1 (C1, see List of Confidential Names) left the facility without leave (AWOL) on September 9, 2021. The facility reported C1 missing to the El Cajon Police Department when the client did not return overnight. Facility had communication with the client's Telecare Dream Team on September 10, 2021. At 6:30 PM, Telecare called the facility to inform them that C1 was found in Mission Bay and was brought to a local hospital for unresponsiveness related to drowning. C1 expired at the local area hospital on September 13, 2021.

During today's visit, LPA conducted interviews and collected pertinent records. At this time, further information is required and future visits may be necessary to determine the outcome of the investigation.

No deficiencies were cited during today's visit.

An exit interview was conducted with the Administrator. A copy of this report and Licensee's Rights (9058 01/16) were provided to the Administrator via electronic mail. An e-mail confirmation was requested upon receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alexandre Vo
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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