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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602406
Report Date: 09/02/2020
Date Signed: 09/02/2020 03:28:10 PM

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:CARLSBAD ELDER CAREFACILITY NUMBER:
374602406
ADMINISTRATOR:JASNA POPOVICHFACILITY TYPE:
740
ADDRESS:1840 BIENVENIDA CIRTELEPHONE:
(760) 729-9800
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:6CENSUS: 6DATE:
09/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:David Swagerty, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Laarni Santiago conducted a case management virtual visit, via video conference, to follow-up on an incident reported to Community Care Licensing. LPA virtually met with David Swagerty, Administrator, during the video call and explained the reason for the call.

Community Care Licensing received an incident report on August 31, 2020, in which it was reported that Resident #1 (R1) [Administrator was provided an LIC 811 Confidential Names List that identifies the resident] was absent without official leave (AWOL) from the facility on August 30, 2020.

During today's visit, LPA interviewed the administrator and R1 and requested additional information on pertinent facility records and additional staff contact information. No deficiencies were cited during today’s visit.

A copy of this report and Licensee Appeal Rights (LIC 9058) were provided to David Swagerty via electronic mail. An electronic email read receipt confirms documents have been received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2020
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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