374604481-5-8-2023-08-AS-DNGN-CRMNMW-20230508103550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604481
Report Date: 05/08/2023
Date Signed: 05/08/2023 10:35:56 AM

Document Has Been Signed on 05/08/2023 10:35 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:	COLUMBIA RESIDENTIAL CARE LLC		FACILITY NUMBER:	374604481
ADMINISTRATOR:	CHANEL BERNARTE		FACILITY TYPE:	735
ADDRESS:	1610 COLUMBIA STREET		TELEPHONE:	(858) 294-3670
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY: 4		CENSUS: 2	DATE:	05/08/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Administrator Chanel Bernarte and House Manager Cody Smith		TIME COMPLETED:	10:45 AM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Chanel Bernarte and House Manager Cody Smith.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 04/30/2023). According to the LIC624: on the morning 04/29/2023, Client #1 (C1) briefly went AWOL (absent without leave) from the facility. [See LIC 811 Confidential Names List for a description of C1.] Facility staff quickly located C1 and escorted them back to the facility unharmed/uninjured.

During today’s visit, LPA performed facility tour and welfare check on C1, verifying that they were indeed unharmed/uninjured. LPA also collected pertinent records and interviewed relevant staff.

According to C1’s latest LIC602 Physician’s Report (dated 04/11/2022), their doctor determined that C1 was able to safely leave the facility unassisted. Interviews and records revealed: On the morning of 04/29/2023, C1 was being driven back to the facility by a relative following an outing. During the drop off, and before facility staff received C1 back inside, C1 took off on foot. The relative alerted facility staff, who quickly caught up to C1, accompanied them on a walk to a nearby shopping plaza, then safely escorted C1 back to the facility.

No deficiencies were identified or cited for the incident. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Bernarte and Smith, 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.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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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