<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804823
Report Date: 05/03/2024
Date Signed: 05/03/2024 05:04:25 PM


Document Has Been Signed on 05/03/2024 05:04 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
SO. CAL AC/SC, 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: 112DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Divina Salinas, Director of NursingTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced Case Management Visit.  LPA was greeted by and met with Director of Nursing, Divina Salinas to discuss the purpose of the visit. 

Today's visit is in response to a self-reported incident documenting a resident's unwitnessed fall. On 4/12/24, Resident 1 (R1) fell in the bathroom, striking their head. Emergency Medical Service (911) was called and R1 was transported to the hospital for evaluation and treatment. Per reporting, the resident sustained a hip fracture.

LPA conducted interviews with staff and obtained and reviewed pertinent records. According to interviews with staff, R1 underwent surgery was transferred from the hospital to a skilled nursing facility. Director Salinas advised LPA that R1 will return to the facility after their rehabilitation.

Based on LPA's investigation, no deficiencies were cited during today's visit. 

An exit interview was conducted with Director, Salinas, who was provided a copy of this report and Appeal Rights (LIC9056 03/22).  Ms. Salinas' signature confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1