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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602461
Report Date: 11/22/2021
Date Signed: 11/23/2021 10:21:21 AM

Document Has Been Signed on 11/23/2021 10:21 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:BADERE RESIDENTIAL CAREFACILITY NUMBER:
374602461
ADMINISTRATOR:RAYMOND BADEREFACILITY TYPE:
735
ADDRESS:9120 LIBRA DRIVETELEPHONE:
(858) 566-0434
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 5DATE:
11/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, Ray BadereTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA was greeted and allowed entry into the facility by Administrator, Ray Badere. LPA discussed the purpose of the visit was to discuss a recent incident and death involving a client.

During today's visit, LPA toured the facility, requested records, and interviewed staff and clients. On 11/12/21, the Department received a self reported incident report involving Client #1 (C1). C1 was eating and began choking. Staff performed the Heimlich maneuver and chest compressions on C1. The paramedics were contacted and transported C1 to the hospital. C1 later passed away at the hospital.

An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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