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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600566
Report Date: 03/25/2022
Date Signed: 03/25/2022 01:17:37 PM


Document Has Been Signed on 03/25/2022 01:17 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:REDWOOD TERRACEFACILITY NUMBER:
374600566
ADMINISTRATOR:LEIF CAMERONFACILITY TYPE:
741
ADDRESS:710 WEST 13TH AVENUETELEPHONE:
(760) 747-4306
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:210CENSUS: 129DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Leif Cameron, Executive DirectorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to follow-up on the death of Resident One (R1). LPA made contact with Executive Director Leif Cameron and advised the reason for the visit. LPA toured the facility and noted no health and safety concerns at the time of visit.

Community Care Licensing Division (CCLD) received an unusual incident report from the facility on 3/24/22 to report the death of the resident. The following is a brief description of the visit:

LPA interviewed Mr. Cameron regarding the circumstances of the residents death. LPA collected pertinent resident file information, relevant responsible party contact information, as well as staff and resident roster information.

Mr. Cameron was advised that additional information including, interviews, calls, and record review may be needed to complete CCLD's investigation at a later date.

An exit interview was conducted with Mr. Cameron, and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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