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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 06/05/2020
Date Signed: 06/05/2020 04:34:20 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:FREDERICKA MANORFACILITY NUMBER:
374603402
ADMINISTRATOR:CRAIG SUMNERFACILITY TYPE:
740
ADDRESS:183 THIRD AVENUETELEPHONE:
(619) 205-4100
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:560CENSUS: 280DATE:
06/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Corinna Norton, Resident Services DirectorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Robbie Jackson conducted a virtual tele-visit case management visit due to COVID-19 to obtain additional information on a self-reported death of Resident 1 (R1). LPA spoke virtually via FaceTime with Corinna Norton, Resident Services Supervisor and discussed the purpose for the visit .

On 5/28/20, a self-reported incident was received from the facility reporting that R1 hit their head on a cabinet. R1 lives independently in the surrounding cottages on the facility property. R1 pushed their emergency pendant to inform staff of the incident. Staff immediately went R1's location and observed a large hematoma on the left side of the head. Staff called 911 and R1 was transferred to Scripps Chula Vista. After the hospital assessment, R1 was transferred to USCD Medical Center with an diagnosis of a brain bleed. On 5/23/20, R1 had emergency surgery to relieve pressure to the brain. R1 did not recover from surgery and was placed on hospice on 6/1/20 and returned back to their home and passed away on 6/3/20. Facility followed proper protocol for this incident/ No further investigation is needed
An exit interview was conducted with Resident Services Director virtually and a copy of this report along with and LIC 811 Confidential Names List and Licensee/Appeal Rights (LIC 9058 01/16) was provided via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Robbie JacksonTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2020
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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