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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600619
Report Date: 09/14/2023
Date Signed: 09/14/2023 05:22:06 PM


Document Has Been Signed on 09/14/2023 05:22 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:LEICHTAG FAMILY ASSISTED LIVING RESIDENCEFACILITY NUMBER:
374600619
ADMINISTRATOR:CARL MEASERFACILITY TYPE:
740
ADDRESS:211 SAXONY ROADTELEPHONE:
(760) 632-0081
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:77CENSUS: 59DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Director of Assisted Living Mary FawellTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Director of Assisted Living Mary Fawell.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/11/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour / welfare check, interviewing R1 and verifying that they were safe and unharmed/uninjured. LPA also reviewed pertinent care records and interviewed multiple relevant staff.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Fawell, to whom a copy of this report, the LIC811 Confidential Names
List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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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