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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 03/06/2023
Date Signed: 03/06/2023 03:59:00 PM


Document Has Been Signed on 03/06/2023 03:59 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:CLOISTERS OF THE VALLEY, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:CINDY NIEDRICHFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 60DATE:
03/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Excecutive Director, Disha HallTIME COMPLETED:
03:45 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) Marisela Garcia-Centeno conducted a case management visit to complete a review regarding a self-reported death of Resident 1 (R1) (See LIC 811 for confidential names) received by CCL on 3/3/2023. LPA met with Executive Director, Disha Hall.

LPA reviewed R1's facility file, toured the facility, and conducted interviews with staff about events leading up to the death. R1 resided at the facility since 7/26/2022. On 3/1/2023, at 10:48 p.m. R1 passed away at the facility, unknown cause of death. During the case management visit LPA reviewed R1's relevant records. LPA requested the death certificate.

No deficiencies were cited during the visit.

An exit interview was conducted with Resident Services Director, River Jon Pagala, to whom a copy of this report and the Licensee Rights (LIC9058 01/2016) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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