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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601952
Report Date: 10/18/2022
Date Signed: 10/18/2022 03:29:00 PM


Document Has Been Signed on 10/18/2022 03:29 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:BROOKDALE OCEANSIDEFACILITY NUMBER:
374601952
ADMINISTRATOR:MANADI, FOUDHILFACILITY TYPE:
740
ADDRESS:3524 LAKE BLVDTELEPHONE:
(760) 945-1811
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:186CENSUS: 96DATE:
10/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Business Services Director Raquel TarangoTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management visit. LPA was greeted and allowed entry by the receptionist and met with Business Services Director Raquel Tarango to whom LPA identified herself and discussed the purpose of the visit.

Today's visit is in response to the reported death of Resident #1 (R1 - See LIC811 Confidential Names List). The date of death is listed as 10/13/2022 and R1 passed away at the 10/13/2022.

LPA obtained additional information on this date. All residents observed appeared appropriate for the facility. All staff the LPA interacted with had a current criminal record clearance. No immediate health or safety issues were identified.

No deficiencies were cited or observed on this date.

An exit interview was conducted with Business Services Director Raquel Tarango. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Business Services Director via hard copy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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