374601134-5-5-2021-08-AS-LSIA-C2QVQF-20210505163817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601134
Report Date: 05/05/2021
Date Signed: 05/05/2021 04:38:43 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 COSTA		FACILITY NUMBER:	374601134
ADMINISTRATOR:	LAVENDER, WESLEY D		FACILITY TYPE:	740
ADDRESS:	7020 MANZANITA ST		TELEPHONE:	(760) 930-0060
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	120	CENSUS: 73	DATE:	05/05/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Wes Lavender, Executive Director and Elizabeth Smith, Resident Care Director		TIME COMPLETED:	11:35 AM

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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced case management virtual visit, due to the COVID-19 pandemic. LPA identified herself and stated the purpose of the visit to Executive Director Wes Lavender and to Resident Care Director Elizabeth Smith.

The facility self-reported a death regarding Resident 1 (R1) to Community Care Licensing on April 14, 2021.

During today's visit, LPA conducted a virtual health and safety check, interviewed the Executive Director and the Resident Care Director. LPA also requested copies of resident records and staff contact information. No deficiencies were cited.

An exit interview was conducted with Executive Director Wes Lavender and Resident Care Director Elizabeth Smith, 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: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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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