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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372008448
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:10:59 PM

Document Has Been Signed on 08/24/2023 12:10 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CASA PACIFICAFACILITY NUMBER:
372008448
ADMINISTRATOR:SARA STEINERFACILITY TYPE:
772
ADDRESS:321 CASSIDY STREETTELEPHONE:
(760) 721-2171
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 14CENSUS: 13DATE:
08/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Program Director Lisa DuTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Case Management - Incident visit. LPA was allowed entry by reception staff. LPA introduced herself to Program Director Lisa Du and discussed the purpose of the visit.

Today's visit was in response to a Death Report (LIC624) which licensee submitted to CCLD San Diego Regional Office. The Death Report, received by CCLD on 08/22/2023 described Client 1's (C1) passing away on 08/19/2023. (See LIC811 Confidential Names List for a description of C1.)

During today's visit, LPA performed a brief tour of the facility and welfare check on clients present, finding no safety concerns.

According to records review and interview with the Program Director, C1 was admitted into the facility on 4/5/2023 from an IMD where C1 received treatment since 09/2022.

No deficiencies were cited for C1's death. No other deficiencies were observed or cited during today's visit. LPA provided guidance to Program Director on Title 22 Regulation, Section 81061(b) - Reporting Requirements.

Program Director stated that the facility will obtain a copy of the death certificate and/or the Medical Examiner's report and will submit to CCLD as soon as available.

An exit interview was conducted with Program Director Du, to whom a copy of this report, LIC811 (Confidential Names List), and the Applicant/Licensee Rights (LIC9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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