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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601952
Report Date: 11/05/2021
Date Signed: 11/08/2021 08:25:25 AM

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:BROOKDALE OCEANSIDEFACILITY NUMBER:
374601952
ADMINISTRATOR:DANIELLE HAUSEMANFACILITY TYPE:
740
ADDRESS:3524 LAKE BLVDTELEPHONE:
(760) 945-1811
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:186CENSUS: 98DATE:
11/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH: Foudhil Manadi, Candi LairdTIME COMPLETED:
01:59 PM
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management visit to follow up on an incident report received on September 17, 2021 LPA Ryan introduced herself, stated the purpose of the visit, was allowed entry and met with Executive Director, Foudhil Manadi and Business Office Manager, Candi Laird.

Community Care Licensing (CCL) received an incident report on September 17, 2021 which stated that two residents were involved in an altercation. Facility staff submitted the incident report along with a SOC 341. Licensee informed all of the relevant parties of the incident.

During today's visit, LPA toured the facility, reviewed resident records, and interviewed staff and residents. No deficiencies were cited.

An exit interview was conducted with Mr Manadi and Ms. Laird. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to the executive director at the conclusion of the visit, an electronic response confirms the receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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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