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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603439
Report Date: 08/19/2020
Date Signed: 08/19/2020 03:30:11 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:CASA DE MANANAFACILITY NUMBER:
374603439
ADMINISTRATOR:JOHNSTON, ROBERTFACILITY TYPE:
740
ADDRESS:849 COAST BLVDTELEPHONE:
(858) 454-2151
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:249CENSUS: 202DATE:
08/19/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Syril Nelson, Resident Services DirectorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Laarni Santiago, conducted an unannounced Case Management virtual visit regarding an incident report submitted to the San Diego Regional Office. Virtual visits are being conducted due to COVID-19. LPA met with Resident Services Director, Syril Nelson and Director of Sales and Marketing, Betty Willis, identified herself, and stated the purpose of the visit.

On August 17th, 2020, the Regional Office received an incident report regarding Resident #1's (R1, see List of Confidential Names), that occurred on August 14th, 2020. During the visit, LPA conducted interviews and requested additional documentation and contact information. No deficiencies were cited.

An exit interview was conducted and a copy of this report, List of Confidential Names, and Licensee's Rights (9058 01/16) were provided to the Executive Director and Resident Services Director via electronic mail. An e-mail receipt confirms the acceptance of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2020
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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