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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604288
Report Date: 06/28/2021
Date Signed: 06/28/2021 07:31:03 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:
(858) 312-8492
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:24CENSUS: 11DATE:
06/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Elena Madsen, Executive DirectorTIME COMPLETED:
02:52 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to follow-up on incident reports that were submitted to Community Care Licensing (CCL). LPA was granted entry into the facility and met with Nimrod Wilwayco, Med Tech, with whom she discussed the purpose of the visit.

An incident report, dated 6/5/2021 and received on 6/9/2021, reported that Resident 1 (R1) [an LIC 811 Confidential Names Listwas provided to identify the resident] experienced a fall in the facility on 5/31/2021, which resulted in a rib fracture.

Additional follow-up was also conducted on an incident report that was received by CCL on 2/2/2021, in which it was reported that Resident 2 (R2) eloped from the facility on 1/28/2021.

During today's visit, LPA observed residents, obtained copies of facility records and interviewed staff. No deficiencies were cited during today's visit.

An exit interview was conducted with Elena Madsen, Executive Director, and a copy of this report and licensee appeal rights were provided via electronic mail. Confirmation of receipt is 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: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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