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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804823
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:05:55 PM


Document Has Been Signed on 07/06/2022 12:05 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
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: 100DATE:
07/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:LaTressa DowningTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit to Administrator Eleanor "LaTressa" Downing.

The Department received an incident report and SOC341 - Report of Suspected Dependent Adult/Elder Abuse from the facility on 5/31/2022 regarding an incident between Resident 1 and Staff 1 on 05/27/2022.

During today's visit, LPA toured the facility and reviewed and obtained copies of facility records.

No deficiencies were cited or observed on this date. An exit interview was conducted with Administrator Eleanor "LaTressa" Downing, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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