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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600637
Report Date: 08/24/2022
Date Signed: 08/24/2022 05:29:50 PM


Document Has Been Signed on 08/24/2022 05:29 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:LA COSTA GLEN CARLSBADFACILITY NUMBER:
374600637
ADMINISTRATOR:KEARNAGHAN, KRISTENFACILITY TYPE:
741
ADDRESS:1950 SILVERLEAF CIRCLETELEPHONE:
(760) 704-1000
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:1233CENSUS: 806DATE:
08/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Kristen Kearnaghan, Executive DirectorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced case management incident visit. LPA was granted entry into the facility and met with Kristen Kearnaghan, Executive Director, with whom she discussed the purpose of the visit.

During today's visit, LPA and the Executive Director discussed three Unusual Incident Reports that were submitted to Community Care Licensing between August 11, 2022 and August 22, 2022. According to the reports submitted, the reported incidents of resident falls occurred between August 10, 2022 and August 17, 2022.

No deficiencies were cited during today's visit. Copies of this report and Licensee/Appeal Rights were provided to the Executive Director at the conclusion of today's visit. Kristen Kearnaghan’s signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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