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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601134
Report Date: 09/28/2020
Date Signed: 09/28/2020 01:13:18 PM

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:SUNRISE AT LA COSTAFACILITY NUMBER:
374601134
ADMINISTRATOR:LAVENDER, WESLEY DFACILITY TYPE:
740
ADDRESS:7020 MANZANITA STTELEPHONE:
(760) 930-0060
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:120CENSUS: 66DATE:
09/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Executive Director, Wesley LavenderTIME COMPLETED:
11:38 AM
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Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced Case Management virtual visit regarding a self-reported incident received at the San Diego Regional Office on September 24th, 2020. Virtual visit conducted via Facetime is due to COVID-19 restrictions. LPA met with Executive Director, Wesley Lavender. LPA identified himself and stated the purpose of the visit.

Incident report indicate that a Resident #1 (R1, see list of confidential names) left the facility unassisted on September 18th, 2020, and returned the same day.

During today's virtual visit, interviews with staff and R1 were conducted. Facility's Absentee Notification Plan was also reviewed (Unsafe Leaving). Additional documentation was also requested. At this time, future visits may be necessary to determine the outcome of the investigation.

An exit interview was conducted, and a copy of this report and Licensee's Rights (9058 01/16) were provided to the Executive Director via electronic mail. An e-mail read receipt confirms acceptance of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2020
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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