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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601258
Report Date: 09/08/2021
Date Signed: 09/08/2021 01:47:33 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:FAIRWINDS - IVEY RANCHFACILITY NUMBER:
374601258
ADMINISTRATOR:SOMMER, JESSICAFACILITY TYPE:
740
ADDRESS:4490 MESA DRTELEPHONE:
(760) 439-8090
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:200CENSUS: 145DATE:
09/08/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:General Manager, Jessica SommerTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Kristina Ryan conducted an unannounced collateral visit to interview a resident for an unrelated complaint investigation at the facility. LPA gained access to the facility, identified herself to General Manager, Jessica Sommer and explained the purpose of the visit.

During today’s visit, LPA Ryan met with and interviewed a resident regarding a complaint at another Community Care Licensed Facility. No deficiencies were observed.

An exit interview was conducted with General Manager, Jessica Sommer and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to the General Manager via email. An electronic receipt of confirmation was requested to be sent by the General Manager upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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