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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:43:57 PM

Document Has Been Signed on 10/05/2023 12:43 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:
10/05/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Manager Mitch Blackwood and Quality Assurance Manager Morgan DavisTIME COMPLETED:
01:15 PM
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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 Manager Mitch Blackwood. LPA then met with Quality Assurance Manager Morgan Davis, who arrived later during the visit.

The facility currently operates under a two-year probationary facility license from CCLD, the result of an 08-22-2022 Stipulation and Waiver, and Order (SW&O). During today’s visit, LPA conducted a general overall inspection of the facility, interviewed staff, reviewed records, and evaluated licensee’s ongoing compliance with the requirements described in the SW&O.

Staff interviews, corroborated by record review, essentially supported: a) licensee has a designated “Orientation Trainer” who conducts/oversees both new hire and regularly scheduled training for staff; b) licensee has a designated “Quality Assurance Manager” who meets with the facility’s program manager at least monthly to ensure trainings are completed on time; and, c) licensee has a designated “Quality Assurance Team” that conducts quarterly internal audits. Furthermore, d) quarterly internal audit results/reports are shared with the Department of Developmental Services (DDS), the San Diego Regional Center (SDRC), the CCLD San Diego Regional Office (RO), and licensee’s own corporate officers/directors; and, e) licensee’s corporate officers/directors discuss quarterly internal audit results/reports at their board meetings. They also supported that: f) licensee conducts Clients’ Personal Rights training (including topics on regulations, types of abuse, Mandated Reporting, and incident reporting) for facility staff, at least twice per year; g) licensee monitors incident reports at least monthly to timely submission, h) licensee maintains required practices regarding medication management (as described in the SW&O); and i) licensee maintains required practices regarding communication between direct care staff and management (as described in the SW&O).


[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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: LIBERTY TRANQUILITY
FACILITY NUMBER: 374604208
VISIT DATE: 10/05/2023
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[CONTINUED FROM LIC 809]

During today’s visit, the facility was clean, safe, sanitary, and in good repair. Staff training records were complete and current. There were no immediate health or safety concerns. The facility was operating consistent with the terms of the SW&O. No deficiencies were observed or issued as part of this compliance visit.

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

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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