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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603590
Report Date: 09/28/2023
Date Signed: 09/28/2023 02:53:36 PM

Document Has Been Signed on 09/28/2023 02:53 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MIRA MESA ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
374603590
ADMINISTRATOR:BENCY JIMENEZFACILITY TYPE:
735
ADDRESS:8933 BOGATA CIRCLETELEPHONE:
(858) 564-8358
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 5DATE:
09/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Caregiver Lourdes Abad and Administrator Bency JimenezTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Lourdes Abad. LPA also met with Administrator Bency Jimenez, who arrived later during the visit.

Today's visit was in response to licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 09/25/2023. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 09/24/2023 at the hospital.

During today’s visit, LPA performed a facility tour and welfare check on remaining clients. LPA also reviewed pertinent records and interviewed relevant staff.

No deficiencies were observed or cited during today's visit. However, LPA issued Technical Assistance (TA) regarding the LIC9172 Functional Capability Assessment form and regarding reporting requirements (see LIC9102-TA pages).

An exit interview was conducted with Abad. A copy of this report, the LIC9201-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to the administrator during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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