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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604065
Report Date: 09/07/2023
Date Signed: 09/07/2023 01:16:17 PM


Document Has Been Signed on 09/07/2023 01:16 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:LAGUNA ESTATES SENIOR LIVINGFACILITY NUMBER:
374604065
ADMINISTRATOR:WESLEY LAVENDERFACILITY TYPE:
740
ADDRESS:1088 LAGUNA DRIVETELEPHONE:
(760) 434-7116
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:214CENSUS: 109DATE:
09/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Assistant Health Services Director Sulema "Sue" AlvarezTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Assistant Health Services Director Sulema "Sue" Alvarez.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/15/2023). The LIC624 described a medication incident involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1.]

During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding that they were safe and alert. LPA also reviewed pertinent care records and interviewed relevant staff.



Based on evidence, circumstances, and context obtained through reviewed records and interviews, no deficiency was cited for the above incident. Also, no deficiency was observed during today’s site visit.

However, LPA issued one (1) Technical Violation (TV) regarding reporting requirements. LPA also provided Technical Assistance (TA) to Licensee regarding a medication cart procedure.

An exit interview was conducted with Alvarez, to whom a copy of this report, the LIC9201-TV, LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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