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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603338
Report Date: 10/25/2022
Date Signed: 10/25/2022 05:32:47 PM


Document Has Been Signed on 10/25/2022 05:32 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:EASY LIVING @ MIRA MESAFACILITY NUMBER:
374603338
ADMINISTRATOR:OLIVER CALCETASFACILITY TYPE:
740
ADDRESS:10136 ZAPATA AVENUETELEPHONE:
(858) 566-7233
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator, Oliver CalcetasTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management visit - Incident. LPA was greeted and allowed entry into the facility by Staff, Julieta Combes. Administrator, Oliver Calcetas arrived during the visit. LPA discussed the purpose of the visit with the administrator.

During today's visit, LPA toured the facility, requested records, and interviewed staff and residents. The administrator self reported an incident involving Resident #1 (R1) that occurred on 08/25/22. R1 sustained discoloration around their eye approximately a half inch by a half inch in size. It is unknown how the discoloration occurred. Staff did not witness an incident involving R1. R1 was transported to the hospital for evaluation and returned to the facility.

No deficiencies were observed. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Administrator, Oliver Calcetas whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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