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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 06/28/2021
Date Signed: 06/28/2021 04:08:04 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: 247DATE:
06/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Director of Resident Services, Corinna NortonTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton, conducted an unannounced case management visit at the facility. LPA gained access to the facility, identified herself to Director of Resident Services, Corinna Norton and explained the purpose of the visit.

The purpose of the visit was to discuss Incident Reports received in our office on June 25, 2021. During today’s visit, LPA requested copies of staff and resident records and conducted interviews with staff and residents. No deficiencies were observed during today’s visit.

An exit interview was conducted with the Norton and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Norton via email. An electronic receipt of confirmation was requested to be sent by the Director of Resident Services 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: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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