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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601329
Report Date: 12/13/2021
Date Signed: 12/13/2021 03:38:52 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:GATEWAY GARDENSFACILITY NUMBER:
374601329
ADMINISTRATOR:ANGELA M.SCOTT-KAPILOFFFACILITY TYPE:
740
ADDRESS:12750 GATEWAY PARK ROADTELEPHONE:
(858) 451-9933
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:72CENSUS: 60DATE:
12/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Cameron Azemikhah, Assisted Living DirectorTIME COMPLETED:
12:16 PM
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Licensing Program Manager (LPM) Denise Powell and Licensing Program Analyst (LPA) Esther Miller, conducted an unannounced Case Management visit. LPM and LPA were allowed entry into the facility after identifying themselves and explained the purpose of the visit with Marisol Barajas, Business Office Manager. During the visit, Cameron Azemikhah, Assisted Living Director, arrived to provide additional information regarding these incidents and pertinent facility records.

The facility submitted self reported SOC341 reports that were received at the San Diego Regional Office on October 19, 2021 and November 18, 2021 regarding theft and loss incidents involving Residents R1 and R2 (see LIC811, Confidential Names List). LPA requested Administrator submit Unusual Incident Reports (LIC624) as is required and provided additional guidance on reporting requirements. During today's visit, LPA obtained relevant records and resident contact information and interviewed Administrator. No deficiencies were cited during this visit.

An exit interview was conducted with Assisted Living Director, and a copy of this report, LIC811 form and Licensee Appeal Rights (LIC9058) will be emailed for facility records.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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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