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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604013
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:23:25 PM

Document Has Been Signed on 12/15/2021 04:23 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:CROWNVIEW PSYCHIATRIC INSTITUTE INC.FACILITY NUMBER:
374604013
ADMINISTRATOR:BRITTANY PERKINSFACILITY TYPE:
772
ADDRESS:1110 CAMINO DEL SOL CIRCLETELEPHONE:
(760) 231-1170
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 6CENSUS: 5DATE:
12/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jennifer VargasTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA met with Administrator Jennifer Vargas and Program Director Karie Peel, and we discussed the purpose of the visit.

Today's visit is in response to the self-reported death of Client 1 (C1 - see LIC811 Confidential Names List). C1 passed away at Scripps La Jolla Hospital, date of death: 12/8/21.

LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility. Additional information was obtained on this date regarding C1's death.

No deficiencies were cited or observed on this date.

An exit interview was conducted with Administrator Jennifer Vargas. The Licensee will be provided a copy of their appeal rights (LIC9056 01/16), via email, along with a copy of this report. An electronic read receipt will serve as confirmation of receipt of documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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