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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372002165
Report Date: 02/18/2022
Date Signed: 02/22/2022 09:10:18 AM


Document Has Been Signed on 02/22/2022 09:10 AM - 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:CABANAS ADULT CARE HOMEFACILITY NUMBER:
372002165
ADMINISTRATOR:CABANAS, ERLOVEFACILITY TYPE:
740
ADDRESS:8031 MONTARA AVENUETELEPHONE:
(858) 689-1872
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:5CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Erlove Cabanas.TIME COMPLETED:
12:15 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) Natasha Persaud conducted a Case Management - Other visit. LPA was greeted and allowed entry into the facility by Administrator, Erlove Cabanas. LPA stated the purpose of the visit was to follow up on a death of a resident.

During today's visit, LPA briefly toured the facility, requested records, and interviewed staff and residents. On 02/14/22, Community Care Licensing received a death report for Resident #1 (R1). The report stated R1 was found unresponsive on 02/13/22. No deficiencies were issued today.

An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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