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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604057
Report Date: 06/14/2021
Date Signed: 06/29/2021 02:15:47 PM

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:ELMCROFT OF LA MESAFACILITY NUMBER:
374604057
ADMINISTRATOR:HEBNER, WESFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:56CENSUS: DATE:
06/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Execute Director, Wes HebnerTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA), Debbie Correia conducted an unannounced case management visit regarding a self-reported incident received at the San Diego Regional Office on June 10th, 2021. LPA Correia was met by Execute Director (ED), Wes Hebner and allowed entry into the facility. LPA Correia identified herself to ED Hebner and stated the purpose of the visit.

During today's visit, LPA briefly toured the facility, obtained pertinent records, and interviewed staff.

Incident report indicated that Resident #1 (R1, see list of Confidential Names LIC811) AWOL'd (absence without leave or prior notice) on 06/09/21, R1 was located approximately 12 miles from the facility, and returned uninjured. Facility made proper notification to R1's responsible parties which included the Primary Care Physician (PCP), Home Health Agency, local law enforcement, and family members. Physician's report indicated the resident did not have wandering behavior, therefore, was not considered an AWOL risk. R1 has been assigned one on one supervision and R1's Primary Doctor made a change order of R1's medication.

Interviews with staff R1 did not have any behavior that were out of baseline. R1 also did not express any threats of harm to self or Based on today's inspection, there were no deficiencies cited.

An exit interview was conducted with ED Wes Hebner and a copy of this report and Licensee Rights (LIC 9058) were provided to the Executive Director via electronic mail. An electronic read receipt confirmation was requested to be sent upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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