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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603356
Report Date: 01/22/2024
Date Signed: 01/22/2024 05:38:40 PM


Document Has Been Signed on 01/22/2024 05:38 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:RAMONA SENIOR LODGE ASSISTED LIVINGFACILITY NUMBER:
374603356
ADMINISTRATOR:SERENA NELSONFACILITY TYPE:
740
ADDRESS:15855 MARMAC DRIVETELEPHONE:
(760) 440-0168
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY:6CENSUS: 5DATE:
01/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Serena Nelson AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Serena Nelson.

Today’s visit was in response to the death of Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1), which licensee self reported. It was reported R1 passed away at the facility on 01/08/2024.

According to records and interviews, C1 was admitted into the facility on 06/18/2016 with primary diagnoses of Paroxysmal atrial fibrillation, congestive heart failure. C1 was sent to the Palomar Hospital on 12/26/2023 related to a fall on the same day. C1 refused surgery and accepted Vitas hospice care at the hospital prior to discharge on 12/27/2023. C1 requested Sea Coast Hospice Care on 12/28/2023 when C1 was back at the assisted living.

LPA briefly performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date.

An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with the Director, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
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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