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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 06/28/2022
Date Signed: 06/28/2022 01:45:47 PM


Document Has Been Signed on 06/28/2022 01:45 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:KELLY, CHANNAFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 68DATE:
06/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Emily DelabarreTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on an incident report. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Assistant Executive Director Emily Delabarre. LPA spoke with Executive Director Channa Kelly on the phone.

The Department received an incident report and SOC341 - Report of Suspected Dependent Adult/Elder Abuse form on 6/7/22. The facility self reported an incident that occurred on 6/03/22 involving Staff 1 (S1) and Resident 1 (R1). [Assistant Executive Director was provided with an LIC811 Confidential Names list to identify individuals].

During today's visit, LPA Ruiz toured the facility, reviewed and obtained copies of facility records, and interviewed residents.

No deficiencies were cited or observed on this date. An exit interview was conducted with Assistant Executive Director Emily Delabarre and Executive Director Channa Kelly via telephone, to whom a copy of this report and the licensee appeal rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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