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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604227
Report Date: 05/17/2021
Date Signed: 05/17/2021 09:57:32 PM

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:ROLFE, BROOKEFACILITY TYPE:
740
ADDRESS:1350 S. EL CAMINO REALTELEPHONE:
(760) 479-1818
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:56CENSUS: 32DATE:
05/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Kimberly Santillian, Executive DirectorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Dawn Segura made a Case Management visit to conduct an investigation into a client death. LPA was granted entry into the facility and met with Kimberly Santillian, Executive Director, to whom she disclosed the purpose of the visit.

A phone call was made to Community Care Licensing (CCL) and a Death Report was subsequently submitted on 5/14/2021, informing that Resident #1 (R1) [facility representative was provided an LIC 811 that identifies the resident] passed away at the facility. According to information provided to CCL, R1 was found on the floor next to their bed on 5/8/2021, was transported to the hospital, and returned to the facility the same day. R1 passed away at 2:50 AM on 5/9/2021.

During today's visit, LPA toured the facility, obtained copies of facility records, and spoke with the Executive Director and facility staff. No deficiencies were cited during today’s visit.

An exit interview was conducted with Kimberly Santillian, and a copy of this report and Licensee Rights (LIC 9058) were provided to her, via email, following the visit. An electronic read receipt confirmation was requested to be sent upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
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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