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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604227
Report Date: 02/25/2021
Date Signed: 02/25/2021 11:47:47 AM

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:SOMERFORD PLACE-ENCINITASFACILITY NUMBER:
374604227
ADMINISTRATOR:Y'LONN, HUDSONFACILITY TYPE:
740
ADDRESS:1350 S. EL CAMINO REALTELEPHONE:
(760) 479-1818
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:56CENSUS: 35DATE:
02/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Staff- Ashley GarciaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Kristina Ryan, initiated a case management investigation regarding a resident death reported to the San Diego Regional Office on February 22, 2021. The virtual visit was conducted via FaceTime due to COVID-19 restrictions. LPA met with Resident Service Director, Ashley Garcia identified herself, and stated the purpose of the virtual visit.

On February 22, 2021 Administrator, Y'Lonn Hudson notified Community Care Licensing that Resident #1 (R1, see List of Confidential Names) had an accident at the facility and subsequently passed away. Death Report was received at the Regional Office on February 24, 2021.

During today's visit, LPA toured the facility, conducted interviews with staff and requested documents. At this time, further investigation is required regarding the resident's death. No deficiencies were issued during this visit.

An exit interview was conducted. A copy of this report and Licensee's Rights (9058 01/16) were provided to the Administrator via electronic mail. An email receipt confirms the acknowledgement of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021
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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