<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 04/20/2023
Date Signed: 04/20/2023 02:06:08 PM

Document Has Been Signed on 04/20/2023 02:06 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:LIBERTY TRANQUILITYFACILITY NUMBER:
374604208
ADMINISTRATOR:SMITH, DAVIDFACILITY TYPE:
737
ADDRESS:1404 ASH STREETTELEPHONE:
(760) 654-6277
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 4DATE:
04/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Registered Nurse Jennifer Peters, Quality Assuance Manager Morgan Davis, and Assistant Program Manager Mitch BlackwoodTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Registered Nurse Jennifer Peters. LPA also met with Quality Assurance Manager Morgan Davis and Assistant Program Manager Mitch Blackwood, who arrived later during the visit.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse and a Special Incident Report (SIR), which licensee self-submitted to the CCLD San Diego Regional Office on 03/27/2023. The reports described a possible personal rights incident involving Staff #1 (S1) and Client #1 (C1) during the early morning of 03/18/2023, as witnessed by Staff #2 (S2). [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Per the written reports, was no physical harm to C1.

During today’s visit, LPA performed a brief facility tour and attempted a welfare check on clients, but all four (4) clients (including C1) were off-site, either at doctor’s appointments or on recreational outings with staff. LPA interviewed pertinent staff and reviewed relevant records.

Based on information gathered in records and interviews, LPA concluded the interaction between S1 and C1 on 03/18/2023 constituted neither client abuse nor a client personal rights violation. C1’s health, safety, and personal rights were not threatened. No deficiency was cited for this incident.

An exit interview was conducted with Davis, 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: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1