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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808315
Report Date: 07/23/2024
Date Signed: 07/23/2024 01:23:27 PM

Document Has Been Signed on 07/23/2024 01:23 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:VELASCO HOME IIFACILITY NUMBER:
370808315
ADMINISTRATOR/
DIRECTOR:		ELIZABETH VELASCOFACILITY TYPE:
735
ADDRESS:1537 LARKHAVEN DRIVETELEPHONE:
(619) 585-1283
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 4DATE:
07/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Caregiver Marites ChiapocoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Marites Chaipoco.

Today's visit was in response to Licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 07/22/2024. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 07/19/2024.

During today’s visit, the remaining four (4) clients in care were all off-site at day programs. However, LPA performed a brief facility tour, finding safety concerns. LPA also collected copies of and reviewed pertinent care records and interviewed relevant staff.

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

An exit interview was conducted with Chiapoco, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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