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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604287
Report Date: 02/22/2022
Date Signed: 02/23/2022 08:33:15 AM


Document Has Been Signed on 02/23/2022 08:33 AM - 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:CADENCE AT POWAY GARDENS - THE SYCAMORESFACILITY NUMBER:
374604287
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12738 MONTE VISTA RDTELEPHONE:
(858) 487-0724
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 3DATE:
02/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Sherrylyn Anding, Resident Service DirectorTIME COMPLETED:
04:41 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced case management visit to follow-up on two incidents reported to Community Care Licensing. LPA introduced herself, was granted entry into the facility, and met with Sherrylyn Anding, Resident Service Director, to whom she disclosed the purpose of the visit. During today's visit, LPA conducted a health and safety check, interviewed staff, and obtained copies of facility records. Elena Madsen, Executive Director, arrived after tour and spoke briefly with LPA.

Community Care Licensing received an incident report on 11/12/21, in which it was reported that Resident #1 (R1 - See LIC811 Confidential Names List) was absent without official leave (AWOL) from the facility on 11/10/21. R1 also eloped on 01/13/22. Facility was aware that physician's report indicated possible wandering behavior and that R1 could not leave unassisted. R1 has since moved out of the facility.

A deficiency is being cited on the LIC809-D in accordance with California Code of Regulations, Title 22. A plan of corrections was discussed and found to have been implemented before visit today.

An exit interview was conducted with Sherrylyn Anding, Resident Service Director, a Plan of Corrections was discussed, and a copy of this report and Licensee Appeal Rights (LIC9058) were provided to the Sherrylyn Anding, Resident Service Director via electronic mail, following the visit. An electronic mail read receipt confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
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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Document Has Been Signed on 02/23/2022 08:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: CADENCE AT POWAY GARDENS - THE SYCAMORES
FACILITY NUMBER: 374604287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2022
Section Cited

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BASIC SERVICES: Basic services shall...include:...assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered....This requirement was not met as evidenced by:
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Based on record review and interviews, the licensee did not provide assistance to 1 of 5 residents, resulting in R1's elopement which posed an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
LIC809 (FAS) - (06/04)
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