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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604062
Report Date: 10/28/2020
Date Signed: 10/28/2020 02:13:07 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 POINT LOMAFACILITY NUMBER:
374604062
ADMINISTRATOR:SHEARER, KELLIEFACILITY TYPE:
740
ADDRESS:3423 CHANNEL WAYTELEPHONE:
(619) 224-7300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:60CENSUS: 39DATE:
10/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Executive Director, Kellie ShearerTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted a Case Management tele-visit. This visit was conducted via FaceTime due to COVID-19. LPA identified herself and discussed the purpose of the visit with Executive Director, Kellie Shearer.

The purpose of the visit was to discuss an Incident Report received in our office on 10/26/2020 regarding an incident that occurred on 10/17/2020. During today’s visit, LPA interviewed staff, requested copies of resident records and briefly toured the facility. No deficiencies were observed during today’s visit.

An exit interview was conducted with the Executive Director, Kellie Shearer and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Kellie Shearer via email with an electronic read receipt.
SUPERVISOR'S NAME: Tony GirolamiTELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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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