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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 03/22/2021
Date Signed: 03/22/2021 12:00:19 PM

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: 245DATE:
03/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Executive Director, Craig Sumner and Executive Assistant, Jolene Hall TIME COMPLETED:
11:43 AM
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) Elizabeth Hamilton conducted a virtual Case Management visit. This visit was conducted via FaceTime due to COVID-19. LPA identified herself and discussed the purpose of the visit with Executive Director, Craig Sumner and Executive Assistant, Jolene Hall.

The purpose of the visit was to discuss Incident Reports received in our office on March 10, 2021, March 15, 2021, March 16, 2021 and March 17, 2021. During today’s visit, LPA interviewed staff, requested copies of staff records and briefly toured the facility. No deficiencies were observed during today’s visit.

An exit interview was conducted with the Executive Director and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Executive Director via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021
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