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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804788
Report Date: 09/10/2021
Date Signed: 09/10/2021 09:32:04 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: 95DATE:
09/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Administrator, Rebecca RayoTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA), Alexandre Vo, conducted a case management visit regarding a death reported to the San Diego Regional Office on September 9, 2021. LPA was allowed entry into the facility after identifying himself and stating the purpose of the visit.

On September 1, 2021, resident #1 (R1, see list of confidential names) had a medical accident and was sent to the hospital after staff attempted life-saving measures. On September 8, 2021, facility was notified by Telecare, Case Manager, that resident expired at a local hospital. LPA briefly interviewed staff to establish a timeline and collected pertinent records. At this time, additional information is required to complete the investigation.

No deficiencies were cited during this visit.

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

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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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