<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601939
Report Date: 03/29/2023
Date Signed: 03/29/2023 05:58:47 PM

Document Has Been Signed on 03/29/2023 05:58 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:SPECIAL FRIENDS-SAGEWOODFACILITY NUMBER:
374601939
ADMINISTRATOR:WOJCIECHOWSKI, MICHELLEFACILITY TYPE:
735
ADDRESS:13411 SAGEWOOD DRIVETELEPHONE:
(858) 312-1687
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
03/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Katherine Carver, House ManagerTIME COMPLETED:
02:56 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Esther Miller cited deficiencies discovered during an unrelated complaint visit. LPA was granted entry after identifying herself by Katherine Carver, House Manager. House Manager signed report but could not stay and make a Plan of Correction with LPA.

On March 29, 2023, House Manager informed LPA that a client was expected to move out by April 6, 2023 after being given a 30 day notice to vacate. Administrator Michelle Wojciechowsky admitted to not submitting a copy of the notice to the Department.

Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC809D and a plan of correction was developed. An exit interview was conducted with House Manager and a copy of this report, along with Licensee/Appeal Rights (LIC9058 03/22), were provided. After the exit interview, House Manager had to leave the facility due to a prior engagement. POC was discussed over the phone with House Manager and caregiver.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/29/2023 05:58 PM - It Cannot Be Edited


Created By: Esther Miller On 03/29/2023 at 02:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SPECIAL FRIENDS-SAGEWOOD
FACILITY NUMBER: 374601939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
80068.5(e)

1
2
3
4
5
6
7
Eviction Procedures. (e) The licensee shall mail or fax to the Department a copy of the 30-day written notice…within five days of giving the notice to the client. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
House Manager offered to provide in-service training to administrative staff regarding eviction procedures. Proof of training will be provided to Community Care Licensing.
8
9
10
11
12
13
14
Based on interviews and record reviews, the licensee did not provide the Department with a copy of the 30 day written notice which posed a personal rights to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Denise Powell
LICENSING EVALUATOR NAME:Esther Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2