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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603402
Report Date: 07/13/2021
Date Signed: 07/14/2021 10:47:35 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:
07/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Resident Services Director, Corinna Norton TIME COMPLETED:
12:30 PM
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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 and identified herself to Resident Services Director, Corinna Norton and explained the purpose of the visit.

The facility self reported an incident regarding Resident 1 (R1) (See LIC 811 Confidential Names) to Community Care Licensing on July 12, 2021. The facility reported that on July 07, 2021, R1 eloped the memory care unit and was found outside of unit.

During today’s visit, LPA conducted interviews and obtains copies of resident records. No deficiencies were cited at this time.

An exit interview was conducted with the Resident Services Director and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC9058 01/16) was provided to the Resident Services Director via email. An electronic receipt of confirmation was requested to be sent by the Resident Services Director 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: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
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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