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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604065
Report Date: 03/22/2024
Date Signed: 03/25/2024 09:41:32 AM


Document Has Been Signed on 03/25/2024 09:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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: 112DATE:
03/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Executive Director Jonathan ThomasTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Jonathan Thomas.

Today's visit was in response to an LIC624 Unusual Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 03/13/24). The facility self-reported a medication management issue with Resident #1(R1) [See LIC 811 Confidential Names List for a description of R1.]

During today’s visit, LPA requested records, and spoke briefly to Jonathan about the incident. There were no deficiencies cited during today's visit.

An exit interview was conducted with Jonathan, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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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