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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804788
Report Date: 07/15/2024
Date Signed: 07/21/2024 09:33:02 PM


Document Has Been Signed on 07/21/2024 09:33 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: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: 88DATE:
07/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Rebecca RayoTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Rebecca Rayo.

Today's visit was in response to a LIC 624A Death Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/11/2024, updated report received on 07/12/24). According to the LIC624A: on 07/01/2024, Resident #1 (R1) was sent to the hospital due to a behavioral episode. R1 passed away at the hospital on 07/05/24 and the cause of death is unknown.

During today’s visit, LPA performed a facility tour/welfare check, collected records, and interviewed the Administrator.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Rebecca, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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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