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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804527
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:40:31 PM


Document Has Been Signed on 08/16/2023 01:40 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:LIWAG'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
370804527
ADMINISTRATOR:NORA B. LIWAGFACILITY TYPE:
740
ADDRESS:3993 CASEMAN STREETTELEPHONE:
(619) 690-1022
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY:6CENSUS: 2DATE:
08/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Nora LiwagTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno made a Case Management visit to follow-up on a resident's death. LPA was granted entry into the facility by Administrator, Nora Liwag, to whom she disclosed the purpose of the visit.

A Incident Report was received by Community Care Licensing (CCL) on August 15, 2023, informing that Resident #1 (R1) [staff was provided an LIC 811 that identifies the Resident] passed away at the facility on August 14, 2023.

During today's visit, LPA conducted a health and safety check, no violations were noted during today's visit. LPA collected R1's records.

An exit interview was conducted with Administrator, Liwag, to whom a copy of this report and the appeal rights (LIC9058 01/16), was provided at the end of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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