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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602972
Report Date: 07/20/2023
Date Signed: 07/20/2023 04:59:21 PM


Document Has Been Signed on 07/20/2023 04:59 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: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: 64DATE:
07/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Executive Director Maria ShetlerTIME COMPLETED:
05:10 PM
NARRATIVE
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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 Executive Director Maria Shetler.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/14/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1].

During today’s visit, LPA performed a brief facility tour and welfare check on residents, finding no concerns. LPA tested the facility's delayed-egress doors, finding no concerns. LPA also collected pertinent records and interviewed relevant staff.

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

An exit interview was conducted with Shetler, 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.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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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