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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604149
Report Date: 07/14/2023
Date Signed: 07/14/2023 06:22:20 PM

Document Has Been Signed on 07/14/2023 06:22 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:NORTH COUNTY CARE HOMEFACILITY NUMBER:
374604149
ADMINISTRATOR:CAMPAS, CARMENFACILITY TYPE:
740
ADDRESS:15042 AMSO STTELEPHONE:
(858) 842-4608
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 8DATE:
07/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:55 PM
MET WITH:Carmen Campas, AdministratorTIME COMPLETED:
06:25 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to verify temporary relocation of residents. LPA identified herself and was granted entry into the facility. LPA disclosed the purpose of the visit to the licensee, Tom Bang, and administrator, Carmen Campas.

On today’s date, the licensee notified Community Care Licensing that residents of New World RCFE were temporarily relocated to the facility in response to an emergency evacuation order initiated because of a gas leak that occurred in the area in which the sister facility is located. Upon LPA's arrival, it was discovered that the evacuation order had just been lifted. During the visit, LPA confirmed that all six residents of New World RCFE had been safely relocated into North County Care Home and observed three residents in the process of being transferred back to their respective facility. LPA observed three residents still safely placed and present in the home. LPA was advised that licensee and administrator are seeking transportation options to have remaining residents transferred back to New World RCFE later this evening.

No deficiencies were issued during today’s visit.

An exit interview was conducted with Carmen Campas, to whom copies of this report and Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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