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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600508
Report Date: 06/24/2022
Date Signed: 06/30/2022 11:06:53 PM

Document Has Been Signed on 06/30/2022 11:06 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VELASCO HOME IIIFACILITY NUMBER:
374600508
ADMINISTRATOR:ELIZABETH VELASCOFACILITY TYPE:
735
ADDRESS:1549 GRAND TETON COURTTELEPHONE:
(619) 691-0761
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
06/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Caregiver Gloria De LaRozaTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced case management visit to follow up on an incident report received 06/23/22 regarding Resident R1. LPA explained the purpose of the visit and was greeted by Caregiver Gloria LaRoza.

Per report, R1 had an witnessed fall on 06/12/22 that resulted in injury. Staff immediately called 911 and R1 was sent to ER and subsequently hospitalized. During today's visit, LPA reviewed resident records for R1 and obtained additional information regarding the fall incident and R1's level of care.

No deficiencies were cited or observed on this date. An exit interview was conducted with Caregiver Gloria, to whom a copy of this report and the licensee appeal rights (LIC9058 01/16) were printed and provided at the facility.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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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