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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601258
Report Date: 08/30/2022
Date Signed: 08/30/2022 01:33:48 PM


Document Has Been Signed on 08/30/2022 01:33 PM - 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, 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: 150DATE:
08/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Krista SweetTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management visit to follow up on an incident report. LPA was greeted by, identified herself to, and discussed the purpose of the visit with General Manager Krista Sweet.

On 7/28/2022, the facility self-reported an incident that occurred on 7/21/2022 involving Resident 1 (R1) where R1 sustained an injury. During today's visit, LPA observed residents in care and interviewed staff. [Krista Sweet was provided with an LIC811 Confidential Names list to identify R1].

An exit interview was conducted with Krista Sweet, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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