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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604401
Report Date: 09/22/2022
Date Signed: 09/22/2022 09:04:12 AM

Document Has Been Signed on 09/22/2022 09:04 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:CASA DEL MANANA LLCFACILITY NUMBER:
374604401
ADMINISTRATOR:HERNANDEZ, CRISTINAFACILITY TYPE:
735
ADDRESS:1190 5TH AVE., #B3TELEPHONE:
(619) 841-4753
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 3DATE:
09/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:14 AM
MET WITH:Licensee, Christina HernandezTIME COMPLETED:
08:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an on-site Case Management visit at the facility. LPA Hamilton was greeted at the front door by Licensee, Christina Hernandez and granted entry after identifying herself. LPA explained the purpose of the visit which was to follow-up on the Case Management visit from September 20, 2022.

On September 20, 2022, the Licensee reported client 1 (C1 – See confidential names list LIC 811) went AWOL on September 13, 2022 and returned. LPA conducted interviews with staff and outside sources and reviewed client records. Deficiencies were cited during today’s visit. See LIC 809D page for citations and plan of corrections.

An exit interview was conducted with Licensee and a copy of this report, LIC 809D, LIC 811 and Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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 2
Document Has Been Signed on 09/22/2022 09:04 AM - It Cannot Be Edited


Created By: Elizabeth Hamilton On 09/22/2022 at 08:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CASA DEL MANANA LLC
FACILITY NUMBER: 374604401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited
HSC
1507.15

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1507.15 - Absentee notification plan for missing residents or participants - Every community care facility that provides adult residential care.... shall... develop... an absentee notification plan for each resident...the plan shall be part of the written Needs and Services Plan...This requirement was not met as evidenced by:
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Licensee stated they would develop a written Absentee Notification Plan for each client in care and submit copies to the Department by October 6, 2022.
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Based on interviews and records reviewed, licensee did not develop a written absentee notification plan for each client. This posed a potential safety risk for 3 out of 3 clients in care.
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Type B
10/06/2022
Section Cited
CCR80061

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80061 - Reporting Requirements (b) Upon the occurance...a report shall be made to the licensing agency within the agency's next working day during its normal business hours.... This requirement was not met as evidenced by:
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Licensee agreed to have themselves and all staff attend a licensing vendor approved training on reporting requirements and provide verification to the department by October 6, 2022.
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Based on interviews and records reviewed, licensee did not contact the licensing agency within the agency's next working day after C1 went AWOL. This posed a potential safety risk to 1 out of 3 clients 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 Powell
LICENSING EVALUATOR NAME:Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
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