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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602919
Report Date: 10/12/2022
Date Signed: 10/12/2022 04:02:03 PM


Document Has Been Signed on 10/12/2022 04:02 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:VILLA ALEGREFACILITY NUMBER:
374602919
ADMINISTRATOR:LOCSIN, FREDERICKFACILITY TYPE:
740
ADDRESS:1938 HIDDEN SPRINGS DRIVETELEPHONE:
(619) 578-8788
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:6CENSUS: 4DATE:
10/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Frederick Locsin, Administrator, and Donnah Locson, LicenseeTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to the facility. LPA Lopez identified herself and was granted entry by Frederick Locsin, Administrator. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Administrator Locsin. Licensee Donnah Locsin was contacted via telephone.

The facility self-reported an incident regarding resident #1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing on October 11, 2022. The facility reported that on October 11, 2022, R1 was sent to the hospital for a noted injury.

During today’s visit, LPA spoke with staff and requested resident records. This case management does need further follow-up and may require additional visits or phone calls. No deficiencies were cited during this visit.

An exit interview was conducted with Licensee Locsin and Administrator Locsin and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 3/22) were provided to the Administrator at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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