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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601258
Report Date: 05/29/2024
Date Signed: 05/29/2024 03:55:13 PM


Document Has Been Signed on 05/29/2024 03:55 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
SAN DIEGO RO, 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: 165DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:General Manager Karl MillerTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Karl Miller.

During today's visit, LPA partially toured the facility, including a random sampling of resident rooms, reviewed facility records, observed and spoke with residents. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed.

No deficiencies were cited on today's date. 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 3/22).
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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