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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603643
Report Date: 04/11/2022
Date Signed: 04/12/2022 09:39:26 AM

Document Has Been Signed on 04/12/2022 09:39 AM - 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:ST. PAUL'S PLAZAFACILITY NUMBER:
374603643
ADMINISTRATOR:STRATMAN, KIMFACILITY TYPE:
740
ADDRESS:1420 E PALOMAR STREETTELEPHONE:
(619) 591-0600
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 300CENSUS: 150DATE:
04/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Executive Director Kim StratmanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Kim Stratman.

Today’s visit was in response to the death of Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1), which licensee self-reported. It was reported R1 passed away on April 4th, 2022 at the facility.

LPA briefly toured the facility, performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date.

An exit interview was conducted with Stratman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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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