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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604294
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:30:21 PM


Document Has Been Signed on 05/24/2022 12:30 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:LAS VILLAS DEL NORTEFACILITY NUMBER:
374604294
ADMINISTRATOR:FARISH, JOLENEFACILITY TYPE:
740
ADDRESS:1325 LAS VILLAS WAYTELEPHONE:
(760) 741-1047
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:198CENSUS: 195DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jolene Farish, Executive DirectorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit regarding a recently reported incident. LPA met with Executive Director (ED) Jolene Farish and explained the purpose of the visit.
On May 10, 2022, Community Care Licensing (CCL) received information regarding an incident self-reported by the facility which took place on May 6, 2022 and involved Resident #1 (R1). Per incident report, R1 was noted to have a skin tear to the left forearm and was observed to be weak and unable to sit up unassisted. Staff obtained the vital signs of R1 and activated emergency services due to low oxygen saturation. During today's visit, LPA interviewed two (2) staff, reviewed documents pertaining to R1, and obtained copies of documents.
No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this reported was provided along with LIC 811- Confidential Names List.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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