<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600800
Report Date: 01/30/2023
Date Signed: 01/30/2023 01:57:05 PM


Document Has Been Signed on 01/30/2023 01:57 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:WESLEY PALMSFACILITY NUMBER:
374600800
ADMINISTRATOR:GESKE, BENFACILITY TYPE:
740
ADDRESS:2404 LORING STREETTELEPHONE:
(858) 274-4110
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:511CENSUS: 315DATE:
01/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Executive Assistant Robert RubioTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on events which licensee self-reported to the Community Care Licensing San Diego Regional Office (RO). LPA was welcomed by and identified himself to Receptionist Atsumi Oda. LPA then met and discussed the purpose of the visit with Executive Assistant Robert Rubio.

On 01-25-2023, the RO received an LIC624 Unusual Incident Report regarding Resident #1 (R1) leaving the facility and not being able to find their way back home. The report said R1’s responsible party was notified and 911 was called. Law enforcement located R1 and returned them to the facility unharmed a few hours later.

During today’s visit, LPA briefly toured the facility, performed a welfare check on R1, collected pertinent records, and interviewed relevant staff. Per their LIC602 Physician’s Report and staff interviews, R1’s doctor determined R1 was able to safely leave the facility unassisted. Records and interviews showed staff followed the facility’s Absentee Notification Plan for R1, and have planned a care conference with R1's responsible party. No deficiencies were identified or cited during today’s visit.

An exit interview was conducted with Rubio, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1