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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603347
Report Date: 12/10/2021
Date Signed: 12/12/2021 03:46:44 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:BROOKE ROAD ELDER CAREFACILITY NUMBER:
374603347
ADMINISTRATOR:PAUL MATTECHECKFACILITY TYPE:
740
ADDRESS:2111 BROOKE ROADTELEPHONE:
(760) 728-9373
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:6CENSUS: 0DATE:
12/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Paul MattecheckTIME COMPLETED:
12:35 PM
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Licensing Program Analyst, (LPA), Kristina Ryan conducted an unannounced closure visit to the facility. LPA was met and granted entry by, Administrator, Paul Mattecheck. LPA identified herself and disclosed the purpose of the visit. On November 19, 2021, LPA Ryan received notification of facility closure from Administrator, Paul Mattecheck. .

During the closure visit, LPA observed the facility to be vacant with no residents residing in facility. Prior to the closure visit, an eviction notice and proper relocation of resident in care was confirmed with responsible party and current facility. As of today, no deficiencies were issued and the facility is considered closed.

An exit interview was conducted with Paul Mattecheck. A copy of this report and Licensee's Appeal Rights (LIC 9058 01/16) were provided to the Administrator via e-mail. A confirmation receipt has been requested.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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