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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 07/24/2020
Date Signed: 07/24/2020 04:00:03 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: 272DATE:
07/24/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director, Craig SumnerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Eva Torres conducted a virtual case management visit via FaceTime to follow up on incident that was reported by the facility on 07/21/20. LPA identified herself, spoke with Administrator, Craig Sumner, and disclosed the purpose of the phone call.

On 07/22/20, LPA contacted the facility and requested the facility's records. On the same day, the requested records were received and reviewed. During today's phone call, LPA spoke with Administrator and obtained additional information surrounding the incident.

An exit interview was conducted with Administrator, Sumner, and the Licensee’s Rights (LIC9058 01/15) along with a copy of this report was provided to the Administrator via email. A reply email or return receipt from the Administrator will confirm receipt of documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 990-1407
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
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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