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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601560
Report Date: 05/13/2022
Date Signed: 05/13/2022 04:24:46 PM


Document Has Been Signed on 05/13/2022 04:24 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:GLENBROOK ASSISTED LIVINGFACILITY NUMBER:
374601560
ADMINISTRATOR:HARNESS, SADIEFACILITY TYPE:
740
ADDRESS:1950 CALLE BARCELONATELEPHONE:
(760) 704-6800
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:95CENSUS: 74DATE:
05/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Sadie Harness, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit. LPA Williamson identified herself and was granted entry by the receptionist. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Sadie Harness, Administrator.

On May 12, 2022, the facility reported a resident death regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing. The facility reported that on May 11, 2022, R1 was found in the bathroom on the floor unresponsive. The facility staff contacted 911, and R1 was transported to the hospital at around 6:30 AM., where she was pronounced deceased on May 11, 2022 at around 4:15 PM.

During today's visit, LPA briefly toured the facility, conducted staff interviews, and requested and obtained records. No deficiencies were cited during the visit.

An exit interview was conducted with Sadie Harness, Administrator and a copy of this report, LIC 811 and Licensee Appeal Rights (LIC9058 01/16) were provided to the Administrator.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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