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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601046
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:40:27 AM


Document Has Been Signed on 03/10/2022 11:40 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
CCLD Regional Office,
, CA



FACILITY NAME:BROOKDALE PLACE OF SAN MARCOSFACILITY NUMBER:
374601046
ADMINISTRATOR:PRESTON, MARIOFACILITY TYPE:
740
ADDRESS:1590 W SAN MARCOS BLVDTELEPHONE:
(760) 471-9904
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:245CENSUS: 158DATE:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Executive Director Mario PrestonTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit regarding a death report that was received by CCL on 1/4/2022 for Resident 1 (R1). LPA identified herself and discussed the purpose of the visit with Executive Director Mario Preston. The purpose of this visit was to follow up on the incident reports regarding Resident 1. (See LIC 811 Confidential Names)

LPA conducted a tour of the facility and observed residents in care.  No immediate health or safety issues were observed on this date.  LPA obtained additional information regarding the incident for R1 on this date.

No deficiencies cited on this date.

An exit interview was conducted with Executive Director Mario Preston. A copy of this report was provided to the administrator via email. An electronic response confirms the documents were received. Licensee Rights (LIC9058 01/2016) were left at the facility.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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