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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600735
Report Date: 07/11/2023
Date Signed: 07/11/2023 02:09:58 PM


Document Has Been Signed on 07/11/2023 02:09 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: 77DATE:
07/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Executive Director Candi LairdTIME COMPLETED:
02:20 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 Executive Director Candi Laird.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 03/20/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1].

During today’s visit, LPA performed a facility tour and welfare check, verifying that R1 was safe and unharmed. LPA also reviewed pertinent care and administrative records and interviewed relevant staff.

No deficiencies were issued for the above incident. Also, no deficiencies were observed or cited during today's visit.

LPA provided Technical Assistance regarding the facility’s absentee notification plan (“Missing Resident Policy”).

An exit interview was conducted with Laird, 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: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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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