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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603419
Report Date: 04/06/2023
Date Signed: 04/06/2023 04:50:02 PM

Document Has Been Signed on 04/06/2023 04:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CASA DEL SOL RTFFACILITY NUMBER:
374603419
ADMINISTRATOR:MANUEL VASQUEZFACILITY TYPE:
735
ADDRESS:1561 E MISSION RDTELEPHONE:
(442) 444-8156
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 2DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:02 PM
MET WITH:Diego Vazquez-La Madrid, CaregiverTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for a case management incident visit. LPA met with Caregiver Diego Vazquez-La Madrid and explained the purpose of the visit. The Licensee Manuel Vazquez was available via Telephone.


The visit was conducted as a result of the licensee self-reporting an incident involving client #1 (C1). The licensee’ self reported this incident by submitting form LIC 624 – Unusual Incident/Injury Report to the Riverside Adult and Senior Care program, Community Care Licensing (CCL) Regional office, which was received in on April 4, 2023.

During today’s visit, LPA conducted interviews with facility staff and reviewed and obtained copies of client records. No deficiencies were cited during today’s visit.


An exit interview was conducted and a copy of this report was provided to Diego Vazquez-La Madrid.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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