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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604087
Report Date: 11/02/2023
Date Signed: 11/02/2023 05:35:49 PM

Document Has Been Signed on 11/02/2023 05:35 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:MOUNTAIN VIEW HOME-DEL VISTA WAYFACILITY NUMBER:
374604087
ADMINISTRATOR:RUSSELL, KATRINAFACILITY TYPE:
735
ADDRESS:16350 DEL VISTA WAYTELEPHONE:
(619) 419-9938
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 4CENSUS: 2DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff Lindsey Russell and Administrator Katrina RussellTIME COMPLETED:
05:45 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 Staff Lindsay Russell. LPA then met with Administrator Katrina Russell, who arrived shortly after.

Today's visit was in response to Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/27/2023). According to the SIR: on 10/26/2023, Client #1 (C1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] C1 was returned to the facility unharmed on 10/27/2023.

During today’s visit, LPA performed a brief facility tour and attempted a welfare check on C1. However, C1 had again eloped on 11/02/2023, and was therefore not present during LPA’s visit. LPA also collected copies of pertinent records and interviewed relevant staff.

According to C1’s latest LIC602 Physician’s Report (dated 09/07/2023): C1 was diagnosed with neurocognitive disorder and epilepsy, and their doctor determined that C1 was not able to safely leave the facility unassisted.

Staff interviews and record review showed: Licensee possessed an Absentee Notification Plan for C1. Following the 10/26/2023 elopement, C1 was indeed unharmed, and Licensee also performed a written reappraisal of C1’s care needs. During both the 10/26/2023 and 11/02/2023 elopements, staff witnessed C1 depart the facility and tried to redirect them back, but C1 did not comply. Staff were not able to follow C1 beyond the facility property boundary, due to needing to supervise the other client in care at the facility. For both incidents, staff notified law enforcement, C1’s responsible person, San Diego Regional Center (SDRC), and CCLD.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MOUNTAIN VIEW HOME-DEL VISTA WAY
FACILITY NUMBER: 374604087
VISIT DATE: 11/02/2023
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[CONTINUED FROM LIC 809]

No deficiencies were cited during today's visit.

An exit interview was conducted with Katrina Russell, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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