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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:24:31 PM


Document Has Been Signed on 01/17/2024 01:24 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:BEN GESKEFACILITY TYPE:
740
ADDRESS:183 THIRD AVENUETELEPHONE:
(619) 205-4100
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:560CENSUS: 260DATE:
01/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director of Resident Services Corinna NortonTIME COMPLETED:
01:30 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) Dang Nguyen and Amy Rodgers conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Director of Resident Services Corinna Norton.

Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 12/28/2023). According to the LIC624: on 12/27/2023, Resident #1 (R1) left the facility and was unable to find their way back home. [See LIC 811 Confidential Names List for a description of R1.] Local police were called; later that same evening police brought R1 back to the facility unharmed.

During today’s visit, LPAs performed a brief facility tour and welfare check on R1, verifying that they were unharmed. LPAs also collected copies of pertinent records and interviewed relevant staff and R1’s responsible person.

According to R1’s latest LIC602 Physician’s Report (dated 11/17/2023), their doctor determined that although R1 had Mild Cognitive Impairment, they were still able to safely leave the facility unassisted. The doctor wrote that R1 was not confused/disoriented, had no wandering behavior, was able to follow instructions, was able to communicate needs, and was independent in all Activities of Daily Living (ADLs). Licensee’s own care appraisals on R1 (dated 11/22/2023 and 11/29/2023, respectively) corroborated that R1 was “active” and independent in all ADLs.

Interviews and records showed: Licensee had a written Absentee Notification Plan, and that staff followed this plan during the incident. Licensee also notified R1’s physician of the incident and performed a timely reappraisal of R1’s care needs, as was required. Following the reappraisal, Licensee relocated R1 to its secured memory care section. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: FREDERICKA MANOR
FACILITY NUMBER: 374603402
VISIT DATE: 01/17/2024
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
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809]

No deficiencies were cited during today's visit. LPAs issued Technical Assistance (TA) regarding the facility’s Absentee Notification Plan.

An exit interview was conducted with Norton, to whom a copy of this report, the LIC9102-TA, 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: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2