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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600488
Report Date: 08/09/2023
Date Signed: 08/09/2023 12:23:51 PM


Document Has Been Signed on 08/09/2023 12:23 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 DE LAS CAMPANASFACILITY NUMBER:
374600488
ADMINISTRATOR:KIMBERLY FINCH-DOMINYFACILITY TYPE:
741
ADDRESS:18655 WEST BERNARDO DRIVETELEPHONE:
(858) 451-9152
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:582CENSUS: 455DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Brooke Harris, AdministratorTIME COMPLETED:
12:23 PM
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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Brooke Harris, Administrator and discussed the purpose of the visit.

Community Care Licensing received an incident report on 7/27/2023 in which it was reported that Resident #1 (R1) was found deceased outside of the facility grounds on 7/26/2023.

Additionally, previously mentioned report received on 7/27/2023 states R1 went missing from the facility on 7/26/2023.

Per records reviewed licensee followed absentee notification plan as necessary. During today's visit, LPA collected pertinent resident records as well as conducted a health and safety check of the residents in care. No deficiencies were cited during today’s visit.

Brooke Harris, Administrator was provided a copy of this report, appeal rights (LIC9058 03/22) and a LIC 811.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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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