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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603584
Report Date: 09/20/2021
Date Signed: 09/20/2021 04:23:47 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:ACTIVCARE AT MISSION BAYFACILITY NUMBER:
374603584
ADMINISTRATOR:DESTEFANI, DAWNFACILITY TYPE:
740
ADDRESS:2440 GRAND AVENUETELEPHONE:
(858) 270-8000
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:60CENSUS: 44DATE:
09/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Executive Director Dawn DeStefaniTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow-up on two incidents. LPA was greeted by, identified herself to, and explained the purpose of the visit to Executive Director Dawn DeStefani.

The facility self reported an incident regarding Resident 1 (R1) and Staff 1 (S1) (See LIC811 Confidential Names List) on September 2, 2021. The facility also self reported a separate incident regarding Resident 2 (R2) on September 3, 2021.

During the visit, LPA toured the facility and reviewed and obtained copies of resident and staff records. At this time both case management incidents require further investigation. No deficiencies were cited during today's visit.

An exit interview was conducted with Executive Director Dawn DeStefani, to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) were provided via electronic mail.
SUPERVISOR'S NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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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