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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604388
Report Date: 03/08/2024
Date Signed: 03/08/2024 02:57:47 PM


Document Has Been Signed on 03/08/2024 02:57 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:SUNSET CLIFFS ELDER CAREFACILITY NUMBER:
374604388
ADMINISTRATOR:TRAVONNA WASHINGTONFACILITY TYPE:
740
ADDRESS:1039 SANTA BARBARA STREETTELEPHONE:
(619) 791-5495
CITY:SAN DIEGOSTATE: CAZIP CODE:
92107
CAPACITY:6CENSUS: 4DATE:
03/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Caregiver Hugo Duran and Co-Administrator Guarav "Gary" Rathi TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Hugo Duran. LPA then met with Co-Administrator Guarav “Gary” Rathi, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report and an LIC624A Death Report, both concerning Resident #1 (R1), which Licensee self-submitted to the CCLD San Diego Regional Office (they were received on 02/27/2024 and 03/08/2024, respectively). [See LIC 811 Confidential Names List for a description of R1.] Per the reports: On 02/24/2024, Licensee’s staff arranged for R1 to be taken to a local emergency room due to change in their condition. R1 was admitted to the hospital. Then on 03/06/2024, R1 passed away at the hospital.

During today’s visit, LPA performed a brief facility tour and welfare check on the remaining residents, finding no safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff.

No deficiencies were observed or cited during today’s visit.

An exit interview was conducted with Rathi, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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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