<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 06/14/2023
Date Signed: 06/14/2023 04:06:48 PM


Document Has Been Signed on 06/14/2023 04:06 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: 274DATE:
06/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Director of Resident Services Corinna NortonTIME COMPLETED:
04:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Director of Resident Services Corinna Norton.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse form, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/01/2023), involving Resident #1 (R1) and Staff #1 (S1). Staff #2 (S2) and Staff #3 (S3) were witnesses. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA briefly toured the facility and performed a welfare check on R1, verifying that they were safe, and showing no injury or pain. LPA also reviewed pertinent care, employment, and investigative records, and interviewed relevant staff.

Due to their baseline memory loss, R1 was not able to participate as a reliable historian/interviewee about the incident itself. R1 resided in the facility’s secured memory care unit. Per their latest LIC602 Physician’s Report (dated 04/12/2023), their primary diagnosis was “Dementia.”

Based on today’s records review and interviews: CCLD was able to establish the veracity of licensee’s self-submitted SOC341. In consideration of the specific context of the above incident, there does not exist a preponderance of evidence showing that staff abused R1, or that staff violated R1’s personal rights.

No deficiencies were cited for the above incident, and no deficiencies were observed during today's visit.

An exit interview was conducted with Norton, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1