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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 04/12/2021
Date Signed: 04/12/2021 05:11:53 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: 58DATE:
04/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Channa Kelly, Executive DirectorTIME COMPLETED:
03:58 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced case management visit, via video conference, due to COVID-19, to follow-up on an incident reported to Community Care Licensing. LPA Segura met virtually with Channa Kelly, Executive Director.

Community Care Licensing received an Unusual Incident/Injury Report on April 8, 2021 reporting an incident that occurred on April 7, 2021, involving two facility residents (R1) and (R2) [Executive Director was provided an LIC 811 Confidential Names List that identifies the residents]..

During today's visit, LPA spoke with Channa Kelly and virtually toured the facility. Copies of facility records were previously requested. No deficiencies were cited during today’s visit.

A copy of this report and Licensee/Appeal Rights (LIC 9058 1/16) were provided to Channa Kelly via electronic mail. An electronic read receipt confirmation was requested to be sent by the Executive Director 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: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
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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