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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603750
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:57:32 PM


Document Has Been Signed on 10/01/2024 04:57 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:VILLA LORENAFACILITY NUMBER:
374603750
ADMINISTRATOR:COLLADO JR, JOSEFACILITY TYPE:
740
ADDRESS:14740 VIA FIESTATELEPHONE:
(858) 583-8480
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:85CENSUS: 68DATE:
10/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee Lorranie BlackTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by and identified herself to Resident Service Director Maureen Manzon. LPA then met and discussed the purpose of the visit with Resident Service Director Maureen Manzon and Licensee Lorraine Black.

Today's visit was in response to an Incident Report reported to CCLD on 9/27/2024. According to the report Staff #1 (S1) recently left the property and did not return. According to the licensee, S1 no longer works at the facility. LPA Rodgers investigated the circumstances surrounding the departure of S1. The investigation included gathering evidence and interviews with staff and Licensee.

No deficiencies were cited for the above incident. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Licensee Lorraine Black , to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy RodgersTELEPHONE: 619-997-4108
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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