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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600637
Report Date: 11/12/2020
Date Signed: 11/12/2020 03:06:36 PM

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:LA COSTA GLEN CARLSBADFACILITY NUMBER:
374600637
ADMINISTRATOR:KASIN, KEITHFACILITY TYPE:
741
ADDRESS:1950 SILVERLEAF CIRCLETELEPHONE:
(760) 704-1000
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:1233CENSUS: 796DATE:
11/12/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Keith Kasin, Executive DirectorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA), Daniel Pena, conducted an unannounced Case Management virtual visit via FaceTime due to COVID-19. LPA spoke with Executive Director, Keith Kasin and Director of Resident Health Services, Mario Preston. LPA identified himself and stated the purpose of the virtual visit.

The San Diego Regional Office was notified of the death of Resident #1 (R1, see List of Confidential Names) on November 12, 2020. During the televisit, LPA conducted interviews and requested additional records. At this time, further investigation is required and future visits may be necessary.

No deficiencies were noted.

An exit interview was conducted and a copy of this report, List of Confidential Names, and Licensee's Rights (9058 01/16) were provided to Director Kasin via electronic mail. An e-mail read receipt confirms acceptance of these documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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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