<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603186
Report Date: 11/01/2021
Date Signed: 11/09/2021 03:45:02 PM

Document Has Been Signed on 11/09/2021 03:45 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:CASA REALFACILITY NUMBER:
374603186
ADMINISTRATOR:ILOVINO, MARY JANEFACILITY TYPE:
735
ADDRESS:294 CAMINO VISTA REALTELEPHONE:
(619) 941-1179
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 4CENSUS: 4DATE:
11/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Caregiver, Maria HernandezTIME COMPLETED:
11:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced case management visit at the facility. LPA was greeted at the front door by Caregiver, Maria Hernandez and granted entry after identifying herself. LPA explained the purpose of the visit.

The facility self-reported an incident regarding Client 1 (C1) (See LIC 811 Confidential Names List) to Community Care Licensing on October 29, 2021. The facility reported that on October 27, 2021, C1 eloped from the facility unnoticed and returned to the facility the same day with minor scrapes.

During today’s visit, LPA conducted interviews and requested client records. This case management needs futher follow up. No deficiencies were cited during this visit.

An exit interview was conducted with Caregiver, Hernandez and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 01/16) were provided via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1