<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603750
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:30:29 PM


Document Has Been Signed on 11/15/2023 04:30 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: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: 60DATE:
11/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive Director Joey Collado and Resident Services Director Amy SalvadorTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 Executive Director Joey Collado and Resident Services Director Amy Salvador.

Today's visit was in response to two (2) LIC624 Incident Reports, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/14/2023 and 08/18/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour and welfare check on R1, finding they were safe. LPA also collected copies of pertinent facility and hospital records and interviewed pertinent staff.

No deficiencies were observed or cited during today's visit. One (1) Technical Violation (TV) was issued regarding Reporting Requirements.

An exit interview was conducted with Collado and Salvador, 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1