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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 03:47:34 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Executive Director, Craig SumnerTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced case management visit at the facility. LPA gained access to the facility and identified herself to Executive Director, Craig Sumner. LPA explained the purpose of the visit.

The facility self-reported an incident regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing on October 25, 2021. The facility reported that on October 24, 2021, R1 eloped from the memory care unit unnoticed. R1 did not leave the facility’s larger campus and was returned by staff the same day with no injuries.

During today’s visit, LPA conducted interviews and requested resident records. No deficiencies were cited during this visit.

An exit interview was conducted with Executive Director and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 01/16) were 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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