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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602731
Report Date: 12/21/2023
Date Signed: 12/21/2023 11:40:48 AM

Document Has Been Signed on 12/21/2023 11:40 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:YAWIPI ARFFACILITY NUMBER:
374602731
ADMINISTRATOR:BRAVO, MARTHA CAROFACILITY TYPE:
735
ADDRESS:3827 WILD OATS LANETELEPHONE:
(619) 399-5875
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY: 4CENSUS: 3DATE:
12/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee Martha CaroTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Martha Caro.

Today's visit was in response to licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 12/20/2023. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 12/18/2023.

During today’s visit, LPA performed a brief facility tour, finding no safety concerns. The remaining clients in care were all off-site at day program during the visit. LPA collected copies of pertinent care records and interviewed relevant staff.

No deficiencies were observed or cited during today’s visit.

An exit interview was conducted with Caro, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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