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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601134
Report Date: 04/13/2021
Date Signed: 04/13/2021 10:44:30 AM

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: 67DATE:
04/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Executive Director, Wesley LavenderTIME COMPLETED:
10:19 AM
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Licensing Program Analyst (LPA) Kristina Ryan, and Licensing Program Manager (LPM) Alexandre Vo, conducted an unannounced case management virtual visit, due to the COVID-19 pandemic. LPA and LPM identified themselves, and stated the purpose of the visit to Executive Director, Wesley Lavender.

The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on February 22, 2021. The incident report stated that on February 15, 2021, R1 was hospitalized with an injury. On February 27 2021, R1 passed away.

On today’s date, LPA and LPM toured the facility, requested copies of facility records, and interviewed staff. No deficiencies were cited at this time.

An exit interview was conducted with Executive Director, Wesley Lavender to whom a copy of this report, LIC811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021
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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