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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804865
Report Date: 05/08/2023
Date Signed: 05/08/2023 12:55:07 PM


Document Has Been Signed on 05/08/2023 12:55 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:CARROLLS RESIDENTIAL CAREFACILITY NUMBER:
370804865
ADMINISTRATOR:BRYAN MEYERSFACILITY TYPE:
740
ADDRESS:655 S MOLLISONTELEPHONE:
(619) 444-3181
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:144CENSUS: 115DATE:
05/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Bryan Meyers and Office Assistant Sarita MendozaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Bryan Meyers and Office Assistant Sarita Mendoza.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/02/2023). According to the LIC624: Resident #1 (R1) departed from the facility on the evening of 04/27/2023. [See LIC 811 Confidential Names List for a description of R1.] By the evening of 04/28/2023, R1 had not yet returned to the facility. Since R1 was absent for 24 hours, per facility policy, facility staff filed a missing persons report with local police and notified R1’s case manager. On 04/29/2023, facility staff received notification that R1 had been admitted to a local hospital.

During today’s visit, LPA performed a facility tour / welfare check on remaining residents in care, collected pertinent records, and interviewed relevant staff. As of LPA’s 05/08/2023 site visit, R1 had not yet returned to the facility.

Per R1’s latest LIC602 Physician’s Report (dated 08/11/2022): their doctor determined that R1 was able to safely leave the facility unassisted. Although R1’s primary diagnosis was schizophrenia, the doctor wrote that R1 was not confused/disoriented and had no wandering or sundowning behaviors. The doctor wrote that R1 was ambulatory, independent in Activities of Daily Living (ADLs), able to follow instructions, and able to communicate needs.

No deficiencies were observed or cited during today's visit.

LPA provided Technical Assistance to licensee regarding their Absentee Notification Plan.

An exit interview was conducted with Mendoza, to whom a copy of this report, the LIC811 Confidential Names List, the LIC9102-TA, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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