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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601560
Report Date: 04/15/2021
Date Signed: 04/16/2021 08:40:11 AM

Document Has Been Signed on 04/16/2021 08:40 AM - 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:GLENBROOK ASSISTED LIVINGFACILITY NUMBER:
374601560
ADMINISTRATOR:HARNESS, SADIEFACILITY TYPE:
740
ADDRESS:1950 CALLE BARCELONATELEPHONE:
(760) 704-6800
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY: 95CENSUS: 70DATE:
04/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Sadie Harness, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Manager (LPM) Rebecca Hedgecock conducted an unannounced Case Management Visit. LPM met with Administrator, Sadie Harness, and discussed the purpose of the visit. Today’s visit is in response to the death of Resident 1 (R1) [refer to LIC 811 Confidential List of Names].

LPM conducted a tour of the facility with Director of Nursing, Josie Ledesma, and briefly interacted with residents in care. No immediate health or safety issues were observed. There were no deficiencies cited or observed at today’s visit. Records were obtained.

An exit interview was conducted with Administrator Harness and a copy of this report along with licensee rights (LIC 9058 01/16), was provided via electronic mail. A read receipt will be requested as confirmation of receipt of documents.
SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Rebecca Hedgecock
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2021
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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