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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602972
Report Date: 05/12/2021
Date Signed: 05/12/2021 06:40:56 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:PLAZA VILLAGE SENIOR LIVINGFACILITY NUMBER:
374602972
ADMINISTRATOR:SHETLER, MARIAFACILITY TYPE:
740
ADDRESS:950 L AVETELEPHONE:
(619) 474-4844
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:85CENSUS: 63DATE:
05/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:51 PM
MET WITH:Administrator, Maria ShetlerTIME COMPLETED:
05:36 PM
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Licensing Program Analyst (LPA), Marisela Garcia-Centeno, conducted a case management visit, via Zoom conference, due to COVID-19, to investigate a report of a resident's death.

A Death Report was received by Community Care Licensing (CCL) on May 7, 2021, reporting that Resident #1 (R1) [Administrator was provided an LIC 811 Confidential Names Listthat identifies the Resident] passed away at the facility on May 6, 2021 at 04:36 AM.

During the visit, LPA interviewed the Administrator, virtually toured the facility, and requested copies of client records. Follow-up visits may be required. No deficiencies were cited during today’s visit.

A copy of this report and Licensee Rights (LIC 9058) were provided to Administrator, Maria Shetler via electronic mail. An electronic read receipt confirms the documents were received.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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