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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804788
Report Date: 11/23/2021
Date Signed: 11/23/2021 09:54:32 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: 98DATE:
11/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee, Rebecca RayoTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Correia conducted an unannounced Case Management visit. LPA Correia met Medical Technician (Med-Tech) Lynn Ocenar at the front door, identified herself, and was granted entry into the facility. Med-Tech Ocenar notified Licensee Rayo, of the visit, who arrived at the facility and met with LPA Correia who disclosed the purpose of the visit.

During today’s visit, LPA conducted a brief tour of the facility, obtained copies of resident records, and conducted staff interviews.

The visit was initiated due to a self reported incident involving client #1, that occurred on November 17, 2021. The incident was reported to Community Care Licensing (CCL) via form LIC 624 – Unusual Incident/Injury Report, which was received in our office on November 19, 2021. Further Investigation is needed before determining findings.

An exit interview was conducted with Licensee Rayo and a copy of this report, and Licensee Rights (LIC 9058 01/16) was provided via email. LPA requested an email read reply response from Licensee Rayo to confirm receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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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