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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603186
Report Date: 10/09/2023
Date Signed: 10/09/2023 11:01:23 AM

Document Has Been Signed on 10/09/2023 11:01 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: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: 3DATE:
10/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:House Manager Arturo Tirado and Nurse Becky AlarconTIME COMPLETED:
11:10 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 House Manager Jose Tirado. LPA also met with Nurse Becky Alarcon, who arrived later during the visit.

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 10/06/2023. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 10/04/2023.

During today’s visit, LPA performed a brief facility tour and welfare check on remaining clients, finding no safety concerns. LPA also collected copies of/reviewed pertinent records and interviewed relevant staff.

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

An exit interview was conducted with Alarcon, 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: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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