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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603750
Report Date: 08/28/2024
Date Signed: 08/28/2024 08:40:47 PM


Document Has Been Signed on 08/28/2024 08:40 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: 66DATE:
08/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Executive Director Joey Collado Jr.TIME COMPLETED:
05:25 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 Executive Director Joey Collado Jr.. LPA then met and discussed the purpose of the visit with Memory Care Director Marie Lou Fikingas.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 8/19/2024). According to the LIC624: on 8/18/2024, Resident #1 (R1) went AWOL (absent without leave) from the facility. [See LIC 811 Confidential Names List for a description of R1.]

As of today’s (08/28/2024) licensing visit, R1 is living in the memory care unit of the facility. LPA observed R1 is safe and unharmed. LPA also reviewed pertinent records and interviewed relevant staff. According to R1’s latest LIC602 Physician’s Report (dated 1/26/2024): R1’s primary diagnoses is Dementia with behavioral disturbances. Doctor determined that R1 is not able to safely leave the facility unassisted. Records and interviews revealed: R1 had lived at the facility for around two (2) years, and this was R1’s first AWOL incident since moving in.



According to the facility’s Absentee Notification Plan/Policy: When a client such as R1 is AWOL from the facility, staff are to search the “surrounding area.” After the unsuccessful search, staff are to notify the administrator or the Resident Service Director. Immediately contact and then law enforcement. The procedure was followed.

[Continued 809-C]

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy RodgersTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VILLA LORENA
FACILITY NUMBER: 374603750
VISIT DATE: 08/28/2024
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[Continued form 809]

CCLD concluded: Facility staff provided needed supervision to R1 leading up to the AWOL. Licensee had a written Absentee Notification Plan as part of R1’s record of care, and staff followed this plan.

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

An exit interview was conducted with Executive Director Joey Collado Jr., 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: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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