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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 03/22/2021
Date Signed: 04/02/2021 12:03:47 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) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 56DATE:
03/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:17 PM
MET WITH:Channa Kelly, Executive DirectorTIME COMPLETED:
03:27 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit, via video conference, due to COVID-19, to investigate a client death.

A Death Report was received by Community Care Licensing (CCL) reporting that Resident #1 (R1) [Executive Director was provided an LIC 811 Confidential Names List that identifies the resident] passed away at the facility on 2/27/2021. According to information provided to CCL, the resident, who was under hospice care, was found unresponsive in bed at approximately 7:30 AM.

During the visit, LPA interviewed the Executive Director, toured the facility, and requested copies of resident records. No deficiencies were cited during today’s visit.

An exit interview was conducted with Channa Kelly, Executive Director, and a copy of this report and Licensee Rights (LIC 9058) were provided to the Executive Director via electronic mail. 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: 03/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021
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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