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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 09:06:25 AM

Document Has Been Signed on 09/22/2022 09:06 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 - OtherUNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Licensee, Christina HernandezTIME COMPLETED:
09:15 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, LPA Hamilton conducted a file review on all clients in care. The facility was missing the client medical assessment information for client 1 (C1 see LIC 811 confidential names list) and incomplete medical assessments for C2 and C3. A deficiency was cited during today’s visit. See LIC 809D page for citation and plan of correction. LPA also advised Licensee of Title 22, Division 6, Chapter 1, Article 6 Continuing Requirements, Section 80068.5 Eviction Notices, 80066 Personnel Records and 80070 Client Records. LPA advised the Licensee how to submit a 30-day Eviction Notices to Community Care Licensing (CCL) for review and what needs to be included in Client and Personnel Records. Technical Advisories given.

An exit interview was conducted with Licensee and a copy of this report, LIC 809D, LIC 81, LIC 9102 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)
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Document Has Been Signed on 09/22/2022 09:06 AM - It Cannot Be Edited


Created By: Elizabeth Hamilton On 09/22/2022 at 08:37 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
CCR
80069(b)(1)

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80069 - Client Medical Assessment (d)(5) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file...the client's medical assessment preformed by a licensed physician...and shall not be more than one year old when obtained. This requirement was not met as evidenced by...
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Licensee stated she would obtain completed Physicians reports for 3 clients in care and submit verification to the Department by October 6, 2022.
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Based on interviews and records reviewed, licensee did not have completed Physician's Reports for 3 clients in care. This posed a potential health risk to 3 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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