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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 07/14/2021
Date Signed: 07/15/2021 07:39:16 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: 270DATE:
07/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Resident Services Director, Corinna NortonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced case management visit to check on the health and safety of residents in care. LPA gained access to the facility, identified herself to Resident Services Director (RSD), Corinna Norton and explained the purpose of the visit.

During today's visit, LPA briefly toured the facility, reviewed resident records, and briefly spoke to a resident in care. No immediate health and/or safety concerns were observed during the visit. No deficiencies were issued during today's visit.

An exit interview was conducted with RSD, and a copy of this report, along with Licensee Appeal Rights (LIC 9058 01/16), were provided to the RSD via email. An electronic receipt of confirmation was requested to be sent by the Licensee of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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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