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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604013
Report Date: 01/30/2025
Date Signed: 01/30/2025 06:41:09 PM

Document Has Been Signed on 01/30/2025 06:41 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:CROWNVIEW PSYCHIATRIC INSTITUTE INC.FACILITY NUMBER:
374604013
ADMINISTRATOR/
DIRECTOR:		MELIESSA MARTINEZFACILITY TYPE:
772
ADDRESS:1110 CAMINO DEL SOL CIRCLETELEPHONE:
(760) 231-1170
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 6CENSUS: 2DATE:
01/30/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Program Administrator, Melissa MartinezTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA discussed the purpose of the visit with Program Administrator, Melissa Martinez.

On 01/28/25, the facility's Program Administrator self reported a client death. The facility reported Client #1 (C1) left the facility on 01/27/25. The facility conducted a search, notified local law enforcement, and notified the client's responsible party. C1's Physician Report dated 10/23/24 indicated C1 can leave the facility unassisted. C1 passed away on 01/27/25.

Today, the facility was briefly toured, records requested and interviews conducted with staff. No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Program Administrator, Melissa Martinez whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Client #1].
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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