374603402-11-2-2023-08-AS-AROS-CX7UXX-20231102155901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 11/02/2023
Date Signed: 11/02/2023 06:59:57 PM

Document Has Been Signed on 11/02/2023 06:59 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	FREDERICKA MANOR		FACILITY NUMBER:	374603402
ADMINISTRATOR:	CRAIG SUMNER		FACILITY TYPE:	740
ADDRESS:	183 THIRD AVENUE		TELEPHONE:	(619) 205-4100
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	560	CENSUS: 244	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Executive Director, Ben Geske		TIME COMPLETED:	03:55 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 Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Executive Director, Ben Geske, after identifying themselves and stating the purpose of the inspection. 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. This is a muti-unit property, with marked entry and exit door on first floor. Elevators are available for residents to use to access all floors. LPA was accompanied by the Campus Director, Lujan during a tour of the facility. A tour of the facility was conducted in the Summer House, Timken wing and Towers area in the community and included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. The last disaster drill was conducted in October 2023. PPE supplies are onsite. The is a large body of water, however it is enclosed with a locked gate.. Passageways were free from obstructions. According to Executive Director, Geske, there are no weapons and/or ammunition stored on the premises. All doors and elevators were operational. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked facility store room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: FREDERICKA MANOR	FACILITY NUMBER: 374603402
	VISIT DATE: 11/02/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked on medication carts. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Staff records review verified that all staff records are complete and compliant. All direct care staff have First Aid certificates and First Aide/CPR certificates, and staff training. Resident records reviewed and confirmed compliant. Administrator’s certification is current.

LPA reviewed the theft and loss policy and procedures. LPAs conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted, this report was discussed with Executive Director, Geske. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director, Geske.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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