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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600735
Report Date: 01/04/2023
Date Signed: 01/04/2023 04:07:38 PM


Document Has Been Signed on 01/04/2023 04:07 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:BROOKDALE CLAIREMONTFACILITY NUMBER:
374600735
ADMINISTRATOR:PIERFAX, JUDITHFACILITY TYPE:
740
ADDRESS:5219 CLAIREMONT MESA BLVDTELEPHONE:
(858) 292-8044
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:214CENSUS: 87DATE:
01/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Administrator Candi LairdTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management Visit. LPA was allowed entry by the receptionist. LPA met, identified herself to, and discussed the purpose of the visit with Administrator Candi Laird.

Today's visit is in response to the self-reported incident which occurred on 11/9/2022 regarding a medical condition of Resident 1 (R1). R1 had a stroke while showering. LPA confirmed that R1 was able to bath self without assistance. (See LIC811 Confidential Names List for explanation of R1).

LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility.

No deficiencies were cited or observed on this date.

An exit interview was conducted with the Administrator Candi Laird. A copy of this report and appeal rights (LIC9058 03/22), were provided via hardcopy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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