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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603439
Report Date: 02/19/2021
Date Signed: 03/17/2021 10:13:44 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: 197DATE:
02/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Syril Nelson, Resident Services DirectorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Laarni Santiago, conducted an unannounced Case Management virtual visit via FaceTime due to COVID-19. LPA spoke with Resident Services Director, Syril Nelson. LPA identified herself and stated the purpose of the virtual visit.

The purpose of the Case Management is to follow-up on a death report received on February 12th, 2021 regarding Resident 1's (R1) (See Confidential Names List on LIC 811 to identify R1) death. During the visit, LPA conducted an interview with Resident Services Director and requested for facility records and contact information .

No deficiencies were noted. 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 Administrator, Rob Johnston via electronic mail. An e-mail read receipt confirms acceptance of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
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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