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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603439
Report Date: 08/24/2020
Date Signed: 08/25/2020 10:38:03 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: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: 205DATE:
08/24/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robert Johnston, Executive DirectorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Laarni Santiago conducted a televisit due to COVID-19. LPA identified herself to the Executive Director, Robert Johnston (ED) and Resident Services Director, Syril Nelson (RSD), and we discussed the purpose of the visit.

This visit was initiated due to a death report received on August 19, 2020, in which Resident 1 (R1) (R1 - See Confidential Names List on LIC811) expired subsequently after a witnessed fall incident that occurred on July 28, 2020. A self-reported Incident report was received in the Regional Office on August 5, 2020. During the fall incident on 07/28/20, facility staff initiated 9-1-1, notified responsible party and R1 was taken to the hospital. On August 6, 2020, R1 was discharged back to the facility under hospice care and expired on August 13, 2020. R1's hospice agency, responsible party and CCL were notified.

During today's tele-visit, LPA spoke with RSD, ED, staff and pertinent witness, and requested copies of R1's records and additional staff contact information.

An exit interview was conducted with Robert Johnston and Syril Nelson. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to them via email and a read receipt confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2020
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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