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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 06/12/2024
Date Signed: 06/12/2024 02:11:26 PM


Document Has Been Signed on 06/12/2024 02:11 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 MANORFACILITY NUMBER:
374603402
ADMINISTRATOR:BEN GESKEFACILITY TYPE:
740
ADDRESS:183 THIRD AVENUETELEPHONE:
(619) 205-4100
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:560CENSUS: 265DATE:
06/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Corinna NortonTIME COMPLETED:
02:17 PM
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit.  LPA was greeted by and met with Director of Resident Services Corinna Norton, to discuss the purpose of the visit. 

Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who suffered a fall and fracture.

LPA interviewed staff and obtained facility records. R1 was discharged back to the facility on June 8, 2024. No deficiencies were cited or observed on this date. 

An exit interview was conducted with Corinna Norton, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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