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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604422
Report Date: 07/06/2021
Date Signed: 07/06/2021 10:20:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:LA JOLLA CASA PACIFICAFACILITY NUMBER:
374604422
ADMINISTRATOR:FERNANDEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5468 PACIFICIA DRTELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: DATE:
07/06/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer Fernandez, Gus FernandezTIME COMPLETED:
10:17 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Jennifer Fernandez, Gus Fernandez
Interview Method: Telephone interview

On 7/6/21, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Susan NguyenTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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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