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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604065
Report Date: 05/24/2022
Date Signed: 05/25/2022 01:17:36 PM


Document Has Been Signed on 05/25/2022 01:17 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:DONELLE WILLIAMSFACILITY TYPE:
740
ADDRESS:1088 LAGUNA DRIVETELEPHONE:
(760) 434-7116
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:214CENSUS: 97DATE:
05/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Executive Director Divinia Nunez and Health Services Director Stefanie AnchetaTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced case management visit. LPA identified herself and stated the purpose of the visit with Executive Director Divinia Nunez and Health Services Director Stefanie Ancheta.

The facility self-reported two incidents. The first incident was regarding Resident 1(R1) and was reported to Community Care Licensing on May 23, 2022. The facility reported that on May 22, 2022, R1 left the facility grounds in a vehicle (AWOL) and was returned to the facility by police that same day.

The second incident was regarding Resident 2 (R2) and was reported to Community Care Licensing on May 23, 2022. The facility reported that on May 21, 2022, R2 was having difficulty swallowing. R2 was sent out to emergency care and a small object was found in the throat.

On today’s date, LPA toured the facility and conducted a health and safety check. LPA briefly interviewed the Executive Director Divinia Nunez and Health Services Director Stefanie Ancheta, and requested copies of facility records. No immediate health and safety concerns were noted and no deficiencies were cited at this time.

An exit interview was conducted with the Executive Director Divinia Nunez , to whom a copy of this report and the LIC9058 Licensee/Appeal Rights were printed and provided at the facility.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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