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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 10/29/2020
Date Signed: 10/29/2020 10:31:05 AM

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: 261DATE:
10/29/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director, Craig SumnerTIME COMPLETED:
10:00 AM
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As a result of COVID-19, Licensing Program Analyst (LPA) Eva Torres conducted a virtual case management visit via FaceTime to follow up on two incidents that were reported to CCLD by the facility. LPA identified herself, spoke with Executive Director, Craig Sumner, and disclosed the purpose of the phone call.

During the meeting, LPA discuss the incidents in question with the Executive Director, and requested additional records. An exit interview was conducted with Executive Director, Sumner, and the Licensee’s Rights (LIC9058 01/16) along with a copy of this report was provided to the Executive Director via email. A reply email or return receipt from the Executive Director will confirm receipt of documents.

SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
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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