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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372008410
Report Date: 02/01/2022
Date Signed: 02/02/2022 10:08:40 AM

Document Has Been Signed on 02/02/2022 10:08 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:TODOS SANTOS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
372008410
ADMINISTRATOR:JOHN DURKEEFACILITY TYPE:
735
ADDRESS:959 TOMORRO LANETELEPHONE:
(760) 723-6273
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 5DATE:
02/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager, David VenezuelaTIME COMPLETED:
04:17 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Case Management visit. LPA was greeted at the front door by House Manager Venezuela and was granted entry after identifying herself and disclosing the purpose of her visit.

The visit was initiated due to a self-reported incident involving client #1 (C1). The licensee’s authorized representative self-reported this incident by submitting form LIC 624 – Unusual Incident/Injury Report to Community Care Licensing (CCL), which was received in our office on January 31, 2022.

During today’s visit, LPA conducted interviews with facility staff and reviewed and secured copies of client records.

No deficiencies were cited during today’s visit. An exit interview was conducted with Licensee Beals and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Licensee Beals and House Manager Venezuela. An electronic reply response was requested as receipt of confirmation.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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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