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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 10/27/2021
Date Signed: 10/28/2021 03:48:56 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: 251DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Executive Director, Craig SumnerTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted by Resident Services Director (RSD), Corinna Norton and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit to both RSD Norton and Executive Director, Craig Sumner. This facility serves five hundred and sixty (560) elderly residents; age 60 and above; one hundred and nineteen (119) may be non-ambulatory and five (5) may be bedridden. Hospice care waiver for fifteen (15). Facility is equipped with delayed egress.

During today's visit, LPA toured the facility's Assisted Living tower and memory care units, and verified compliance with infection control practices. LPA and Executive Director, Sumner reviewed the facility’s COVID-19 Mitigation Plan. LPA observed one central entry point; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of disinfectants and PPE.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Executive Director, Sumner and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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