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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604288
Report Date: 10/02/2020
Date Signed: 10/02/2020 04:32:25 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:CADENCE AT POWAY GARDENS - THE PALMSFACILITY NUMBER:
374604288
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12708 MONTE VISTA RDTELEPHONE:
(800) 811-9595
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:24CENSUS: 21DATE:
10/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:46 PM
MET WITH:Jay Johnson, Executive DirectorTIME COMPLETED:
04:07 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) Dawn Segura conducted a case management virtual visit, via video conference, to follow-up on an incident reported to Community Care Licensing. LPA virtually met with Jay Johnson, Executive Director, during the video call.

Community Care Licensing received an incident report on October 2, 2020, in which it was reported that Resident #1 (R1) [Executive Director was provided an LIC 811 Confidential Names List that identifies the resident] sustained an injury on September 27, 2020.

During today's virtual visit, LPA interviewed the executive director, toured the facility, and obtained additional information. No deficiencies were cited during today’s visit.

A copy of this report and Licensee Appeal Rights (LIC 9058) were provided to Jay Johnson via electronic mail. An electronic mail read receipt confirmation was requested to be sent to LPA 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: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
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