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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600800
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:19:41 PM


Document Has Been Signed on 05/09/2023 02:19 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: 312DATE:
05/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Assistant Rowena Lomboy TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Assistant Rowena Lomboy, and discussed the purpose of the visit.

Community Care Licensing received an incident report on 05/01/2023 in which it was reported that Resident #1 (R1) was physically injured by an unknown source.

During today's visit, LPA collected pertinent resident records as well as conducted a health and safety check of the residents in care. No deficiencies were cited during today’s visit.

Executive Assistant Rowena Lomboy was provided a copy of this report, appeal rights (LIC9058 03/22) and a LIC 811.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
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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