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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600661
Report Date: 08/14/2024
Date Signed: 08/20/2024 11:47:01 AM


Document Has Been Signed on 08/20/2024 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:CALIFORNIA HOME FOR SENIORSFACILITY NUMBER:
374600661
ADMINISTRATOR:GLORIA S. QUILLOPEFACILITY TYPE:
740
ADDRESS:1061 E. BRADLEY AVENUETELEPHONE:
(619) 448-2870
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:15CENSUS: 13DATE:
08/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Assistant Administrator Silvana HuertaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Administrator Silvana Huerta.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/12/2024). According to the LIC624: on 08/11/2024, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 returned to the facility unharmed on 08/11/2024.

During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed staff and the Assistant Administrator.

No deficiencies were cited during today's visit.

An exit interview was conducted with Silvana, to whom a copy of this report, the LIC809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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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