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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603870
Report Date: 05/03/2024
Date Signed: 05/03/2024 05:40:42 PM


Document Has Been Signed on 05/03/2024 05:40 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:LA CRUZ SENIOR CARE, INCFACILITY NUMBER:
374603870
ADMINISTRATOR:CRUZ, LINDAFACILITY TYPE:
740
ADDRESS:1882 EUCLID AVENUETELEPHONE:
(619) 401-5314
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:6CENSUS: 3DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator Linda CruzTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Administrator Linda Cruz.

Community Care Licensing received an incident report on 4/15/24 in which it was reported that Resident #1 (R1) had an witnessed fall on 4/12/24. There was an additional report received in the regional office on 5/2/24 which gave additional information regarding the same incident on 4/12/24.

During today's visit, LPA collected records, conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit.

An exit interview was conducted with Administrator Linda Cruz who was also provided a copy of their appeal rights (LIC9058 03/22),this report and their signature on this form, acknowledges receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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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