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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601952
Report Date: 01/04/2023
Date Signed: 01/04/2023 10:40:26 AM


Document Has Been Signed on 01/04/2023 10:40 AM - 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:ADAMS,VALORIEFACILITY TYPE:
740
ADDRESS:3524 LAKE BLVDTELEPHONE:
(760) 945-1811
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:186CENSUS: 92DATE:
01/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Valorie AdamsTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management Visit. LPA was allowed entry by the receptionist. LPA met, identified herself to, and discussed the purpose of the visit with Administrator Valorie Adams. Executive Director Christopher Burk arrived during the visit.

Today's visit is in response to the self-reported incident which occurred on 11/2/2022 regarding the fall of Resident 1 (R1). R1 was holding onto Resident 2's electric scooter when R1 fell (R2 - see LIC811 Confidential Names List for explanation of R1 and R2). Staff present did not witness the fall. R1 has been advised not to hold onto anyone's electric scooter.

LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility.

No deficiencies were cited or observed on this date.

An exit interview was conducted with the Executive Director Christopher Burk. A copy of this report and appeal rights (LIC9058 03/22), were provided via hardcopy.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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