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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604257
Report Date: 09/21/2021
Date Signed: 09/21/2021 05:34:56 PM

Document Has Been Signed on 09/21/2021 05:34 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:FLORES HOMESFACILITY NUMBER:
374604257
ADMINISTRATOR:FLORES, PETER PANGILINANFACILITY TYPE:
735
ADDRESS:17080 BROKEN BOW CTTELEPHONE:
(858) 386-6153
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY: 4CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Peter Flores, AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced Case Management visit regarding incident reports that were received in the Regional Office on today's date and on September 7, 2021 for client #1 (C1)(See Confidential Names List - LIC 811). LPA arrived at the facility, was greeted by Administrator Peter Flores and was granted entry after identifying himself and disclosing the purpose of the visit, which was to conduct a Case Management visit to follow up on the incident reports/ AWOL for C1.

LPA toured the facility inside and out, reviewed facility and client records, and made copies of records. According to the records reviewed, C1 is able to leave the facility unassisted. Facility has an AWOL plan in place and also has an individual AWOL plan for C1. The San Diego Police Department was contacted on the morning of September 21, 2021 when C1 did not return to the facility and then a missing person's report was made. C1 is currently hospitalized at Palomar Medical Center in Escondido for injuries sustained while AWOL. No deficiencies were cited during today's visit.

An exit interview was conducted with Mr. Flores and a copy of this report, the LIC 811, along with Licensee/Appeal Rights (LIC 9098 01/16) were provided to him via the email address he provided to LPA; he expressed that he would send a confirmation upon receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Adam Hamer
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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