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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372008416
Report Date: 01/25/2023
Date Signed: 01/26/2023 08:04:56 AM

Document Has Been Signed on 01/26/2023 08:04 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:VIA CALLADOFACILITY NUMBER:
372008416
ADMINISTRATOR:TYRONE POWELLFACILITY TYPE:
735
ADDRESS:772 VIA CALLADOTELEPHONE:
(760) 730-5082
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 4DATE:
01/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Administrator Maria DeGuzman and Caregiver Gina BaluyutTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on events which licensee self-reported to the Community Care Licensing San Diego Regional Office (RO). LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Gina Baluyut. LPA also met with and discussed the purpose of the visit with administrator Maria DeGuzman, who arrived later during the visit.

On 01-24-2023, facility staff notified the RO via phone call about: Client #1 (C1) developed a productive cough on 01-23-2023. [See LIC 811 Confidential Names list for a description of C1]. C1’s physician was notified, and appointment was set up for C1 to take place on 01-25-2023. During the afternoon of 01-24-2023, C1 passed out while sitting. 911 was called and CPR was performed on C1 by staff and paramedics, but C1 died at the facility.

During today’s visit, LPA briefly toured the facility, performed a welfare check on clients in care, collected pertinent records, and interviewed relevant staff. No deficiencies were identified or cited during today’s visit.

An exit interview was conducted with DeGuzman, to whom a copy of this report, the Confidential Names list (LIC 811), and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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