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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603395
Report Date: 11/30/2020
Date Signed: 11/30/2020 10:16:43 AM

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:SUNRISE ASSISTED LIVING AT LA JOLLAFACILITY NUMBER:
374603395
ADMINISTRATOR:HOLLINGSWORTH, TRACIFACILITY TYPE:
740
ADDRESS:810 TURQUOISE STTELEPHONE:
(858) 488-4300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:76CENSUS: 46DATE:
11/30/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Traci Hollingsworth, Executive DirectorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Daniel Pena conducted a case management virtual visit, via FaceTime, due to COVID-19. LPA identified himself to Executive Director, Traci Hollingsworth and explained the purpose of the visit.

During today's visit, LPA delivered an amended LIC9099 Complaint Investigation Report, originally dated 10/30/2020.

An exit interview was conducted with Director Hollingsworth. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to the Director via email.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020
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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