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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804788
Report Date: 10/09/2020
Date Signed: 10/29/2020 11:43:18 AM

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: 94DATE:
10/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Administrator, Rebecca RayoTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced Case Management virtual visit regarding incident report received at the Regional Office on October 7th, 2020. Virtual visit was conducted via FaceTime and due to COVID-19 restrictions. LPA met with Administrator, Rebecca Rayo, identified himself and stated the purpose of the call.

During today's visit, LPA interviewed residents and staff, surrounding the circumstances of incident that a resident sustained injuries on Saturday, October 3, 2020, between the time period of 8:30 PM and 9:30 PM. At this time, further investigation is required and future visits may be necessary to conclude the findings. No deficiencies were cited.

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

DATE: 10/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020
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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