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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604121
Report Date: 03/21/2022
Date Signed: 03/21/2022 05:07:58 PM

Document Has Been Signed on 03/21/2022 05:07 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:WINNETKA HOMEFACILITY NUMBER:
374604121
ADMINISTRATOR:SEACORD, BRIANFACILITY TYPE:
734
ADDRESS:3526 WINNETKA DRTELEPHONE:
(619) 470-0804
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY: 5CENSUS: 4DATE:
03/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Brian Seaord, AdministratorTIME COMPLETED:
10:37 AM
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Licensing Program Analyst (LPA) Esther Miller conducted a case management visit. LPA was greeted and allowed entry by Tizianna Lorenzana, nurse. LPA met with Brian Seacord, Administrator, to whom the purpose of the visit was disclosed to.

During today's visit, LPA briefly toured the facility, requested records, and interviewed staff. On 03/18/22, Community Care Licensing received a death report for Client 1 (C1 - See LIC811 Confidential Names List). The report stated that, on 03/16/22, C1 passed away in the facility. No deficiencies were issued today and no health or safety issues were identified.

An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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