370808500-9-1-2023-08-AS-DNGN-CV9RL2-20230901130626

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370808500
Report Date: 09/01/2023
Date Signed: 09/01/2023 01:06:41 PM

Document Has Been Signed on 09/01/2023 01:06 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:	NORTH CORDOBA MANOR		FACILITY NUMBER:	370808500
ADMINISTRATOR:	ESPERANZA TAPIA		FACILITY TYPE:	735
ADDRESS:	4120 NORTH CORDOBA AVENUE		TELEPHONE:	(619) 670-5440
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY: 6		CENSUS: 4	DATE:	09/01/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Staff Tony Tapia		TIME 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 Staff Tony Tapia.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/31/2023). According to the LIC624: on 08/29/2023, Client #1 (C1) left the facility, and did not return after 24 hours had elapsed. [See LIC 811 Confidential Names List for a description of C1.]

During today’s visit, LPA performed a facility tour and welfare check on the remaining clients in care, finding no immediate safety concerns. (As of LPA’s 09/01/2023 site visit, C1 had not yet returned to the facility). LPA also reviewed pertinent records and interviewed relevant staff.

According to C1’s latest LIC602 Physician’s Report (dated 07/28/2023), their doctor determined that C1 was able to safely leave the facility unassisted.

Interviews and records showed: Licensee possessed a written Absentee Notification Plan as part of C1’s record of care, as required.. Once it was determined that C1 was a missing person, facility staff timely notified law enforcement, C1’s social worker, and CCLD, thus meeting reporting requirements.

No deficiencies were cited for this incident. No deficiencies were observed or cited during today's visit. LPA provided Technical Assistance (TA) regarding the facility’s Absentee Notification Plan.

An exit interview was conducted with Tapia, to whom a copy of this report, the LIC9102-TA, 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: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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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