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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601560
Report Date: 04/15/2021
Date Signed: 04/15/2021 12:36:50 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: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 - IncidentUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Administrator, Sadie HarnessTIME COMPLETED:
11:49 AM
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management virtual visit, due to the COVID-19 pandemic. LPA identified herself and stated the purpose of the visit to Administrator, Sadie Harness.

The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on April 9, 2021. The incident report stated that on April 8, 2021, R1 was hospitalized with an injury. On April 9, 2021, R1 passed away.

On today’s date, LPA requested copies of facility records and interviewed staff. No deficiencies were cited at this time.

An exit interview was conducted with Administrator, Sadie Harness to whom a copy of this report, LIC811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
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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