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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 07/30/2020
Date Signed: 07/30/2020 05:33:16 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:CLOISTERS OF THE VALLEY, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:KELLY, CHANNAFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2266
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 56DATE:
07/30/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Administrator, Channa KellyTIME COMPLETED:
03:44 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) Elizabeth contacted the facility by telephone to conduct an unannounced case management visit via FaceTime due to COVID-19. LPA identified herself and discussed the purpose of the call with Administrator, Channa Kelly.

Today’s visit was in response to two Unusual Incident Reports, one dated June 27, 2020 and submitted to Community Care Licensing on June 30, 2020, and the second one dated and submitted to Community Care Licensing on July 24, 2020. During today’s visit, Administrator Channa Kelly reported an unrelated incident that occurred on July 27, 2020. This incident will be addressed separately with additional follow-up as needed.

During today's visit, LPA interviewed staff and requested resident records maintained by the facility and obtained additional information about the incidents. LPA also provided guidance on reporting requirements.

No deficiencies were cited during today’s visit. An exit interview was conducted with Administrator Channa Kelly via FaceTime and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to Administrator, Channa Kelly via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Tony GirolamiTELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
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