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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604057
Report Date: 10/20/2022
Date Signed: 10/20/2022 03:39:50 PM


Document Has Been Signed on 10/20/2022 03:39 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:PLATEAU VILLAGE MEMORY CAREFACILITY NUMBER:
374604057
ADMINISTRATOR:DIVINA NUNEZFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:56CENSUS: 34DATE:
10/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Divinia Nunez, Executive Director TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on incident report received by Community Care Licensing on 10/12/22. LPA met with Divinia Nunez, Executive Director (ED) and discussed the purpose of the visit.

On 10/12/22, the facility self- reported an incident that occurred on 10/5/22. Resident (R1) sustained an injury to the right ankle. Per ED, R1 did not have a recent fall or incident that would have caused the injury that was reported on 10/12/22. On 7/30/22, at 1:00 am, R1 was found awake on the floor by a staff member. R1's injury was assessed by the facility and a hospice agency, there were no injuries noted.

During today's visit, LPA Williamson conducted interviews with staff, reviewed resident records and obtained documentation. This incident requires further investigation.

No deficiencies were issued during today's visit. An exit interview was conducted with Divinia Nunez, Executive Director (ED), to whom a copy of this report, Confidential Names (LIC 811) and the Licensee's/Appeal Rights (LIC 9058 01/16) were provided to ED.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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