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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804823
Report Date: 10/25/2021
Date Signed: 10/25/2021 10:54:44 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:ST. PAUL'S VILLAFACILITY NUMBER:
370804823
ADMINISTRATOR:ELEANOR DOWNINGFACILITY TYPE:
740
ADDRESS:2340 FOURTH AVENUETELEPHONE:
(619) 232-2996
CITY:SAN DIEGOSTATE: CAZIP CODE:
92101
CAPACITY:200CENSUS: 99DATE:
10/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:LaTressa DowningTIME COMPLETED:
10:05 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on multiple incidents. LPA was greeted by, identified herself to, and explained the purpose of the visit to Administrator Eleanor "LaTressa" Downing.

The facility self reported Resident 1's (R1) elopement that occurred on 10/14/2021 (See LIC811 for Confidential Names List). Facility staff observed R1 walking outside the facility and escorted R1 back to the facility. The facility also reported two additional incidents that occurred on 8/20/2021 and 8/21/2021 respectively.

During the visit, LPA interviewed and discussed the facility's Absentee Notification Plan with the Administrator and Director of Nursing.

No deficiencies were cited during today's visit. An exit interview was conducted with Administrator LaTressa Downing, to whom a copy of this report and the Licensee Rights (LIC9058 01/16) were provided via email.
SUPERVISOR'S NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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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