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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601258
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:00:04 PM


Document Has Been Signed on 11/20/2023 04:00 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: 166DATE:
11/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:General Manager Karl MillerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to General Manager Karl Miller and Health and Wellness Manager Martha Grant.

During today's visit, LPA provided the General Manager and Health and Wellness Manager consultation and technical assistance regarding reporting requirements, resident assessments, level of care needs, and eviction procedures.

No deficiencies were observed or cited during today's visit. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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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