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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603565
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:31:30 PM


Document Has Been Signed on 10/01/2024 04:31 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:LA VIDA REALFACILITY NUMBER:
374603565
ADMINISTRATOR:GARCIA, KIMBERLYFACILITY TYPE:
740
ADDRESS:11588 VIA RANCHO SAN DIEGOTELEPHONE:
(619) 660-5778
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:177CENSUS: 120DATE:
10/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Assisted Living Director Yvonne HarmonTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit to follow-up on incidents reported to Community Care Licensing. LPA introduced herself and discussed the purpose of the visit with Assisted Living Director Yvonne Harmon.

On September 30, 2024, Community Care Licensing received two self reported SOC341-Report of Suspected Dependent Adult/Elder Abuse forms in regards to two separate incidents involving Staff 1 (S1), Resident 1 (R1) and Resident 2 (R2). [Assisted Living Director was provided with an LIC811 Confidential Names list to identify individuals].

During today's visit, LPA conducted a health and safety check and collected records.

An exit interview was conducted with Assisted Living Director Yvonne Harmon to whom a copy of this report and Licensee Appeal Rights (LIC 9058) were provided to.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
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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