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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603439
Report Date: 03/16/2021
Date Signed: 03/16/2021 05:13:38 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: 197DATE:
03/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Syril Nelson, Resident Services DirectorTIME COMPLETED:
02:30 PM
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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 visit is to follow-up on a Case Management visit that commenced on February 19, 2021 regarding a death report received in the San Diego Regional Office on February 12th , 2021. During the visit, LPA conducted an interview with pertinent witness and attempted interview with Resident 2 (R2) (See Confidential Names List on LIC 811 to identify R2). LPA obtained additional 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: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
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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