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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804788
Report Date: 08/21/2020
Date Signed: 08/21/2020 01:14:42 PM

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:CASA EL CAJONFACILITY NUMBER:
370804788
ADMINISTRATOR:REBECCA RAYOFACILITY TYPE:
740
ADDRESS:306 SHADY LANETELEPHONE:
(619) 440-1335
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:99CENSUS: 93DATE:
08/21/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Rebecca RayoTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced Case Management virtual visit to initiate an investigation regarding an incident report that was received at the San Diego Regional Office on August 19, 2020. Virtual visit was conducted through FaceTime due to COVID-19 restrictions. LPA met with Administrator, Rebecca Rayo, identified himself, and stated the purpose of the visit.

Incident report indicated that Resident #1 (R1, see List of Confidential Names), left the facility without signing out at the front desk. While out in the community, R1 was struck by a vehicle and was admitted to the hospital. Law enforcement was contacted, as well as, notifications were made to the physician and other interested parties. Additional documents were requested. No deficiencies cited at this time. Future visits may be necessary to conclude the investigation.

An exit interview was conducted, and a copy of this report, Licensee's Rights (9058 01/16), and List of Confidential Names were sent to the Administrator via electronic mail. An e-mail receipt confirms acceptance of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
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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