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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 04/15/2022
Date Signed: 04/15/2022 12:10:06 PM


Document Has Been Signed on 04/15/2022 12:10 PM - It Cannot Be Edited

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: 252DATE:
04/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Craig Sumner, Executive DirectorTIME COMPLETED:
10:31 AM
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced Case Management visit related to an incident report. LPA identified herself and was allowed entry into the facility by Corinna Norton, Director of Resident Services. LPA discussed the purpose of the visit with Craig Sumner, Executive Director.

On March 29, 2022, the facility self reported an unusual incident to the Department regarding Staff 1's (S1) medical emergency. During the incident, the facility observed that Resident 1 (R1) had missing medications. During today's visit, LPA briefly toured the facility clinic, interviewed staff, and requested copies of facility records. No deficiencies were cited during today's visit.

Additional guidance was provided regarding reporting requirements. LPA Miller discussed over email and during this visit the level of detail needed to properly convey the nature of events reported.

An exit interview was conducted with Executive Director and a copy of this report and Licensee/Appeal Rights (LIC9058 FAS 01/16) were provided to Executive Director.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
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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