<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604065
Report Date: 08/11/2020
Date Signed: 10/14/2020 11:15:42 AM

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:LAS VILLAS DE CARLSBADFACILITY NUMBER:
374604065
ADMINISTRATOR:BLOOM, CHARLIEFACILITY TYPE:
740
ADDRESS:1088 LAGUNA DRIVETELEPHONE:
(760) 434-7116
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:214CENSUS: DATE:
08/11/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director, Charles BloomTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced Case Management virtual visit regarding an incident report submitted to the San Diego Regional Office. Virtual visits are being conducted due to COVID-19 and was completed over FaceTime. LPA met with Executive Director, Charles Bloom, identified himself, and stated the purpose of the visit.

On August 5th, 2020, the Regional Office received an incident report regarding Resident #1's (R1, see List of Confidential Names), fall that occurred on July 31st, 2020. During the visit, LPA conducted interviews and requested additional documentation. No deficiencies were cited.

An exit interview was conducted and a copy of this report, List of Confidential Names, and Licensee's Rights (9058 01/16) were provided to the Executive Director via electronic mail. An e-mail receipt confirms the acceptance of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1