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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604501
Report Date: 09/05/2023
Date Signed: 09/05/2023 06:21:27 PM

Document Has Been Signed on 09/05/2023 06:21 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:DEL REY SPRINGSFACILITY NUMBER:
374604501
ADMINISTRATOR:GONZALEZ, EDUARDOFACILITY TYPE:
735
ADDRESS:1181 PLAZA AMPARADATELEPHONE:
(619) 990-8870
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 4CENSUS: 2DATE:
09/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Staff Genaro Suarez and Licensee Eduardo "Eddie" Gonzalez, Jr.TIME COMPLETED:
06:30 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 Staff Genaro Suarez. LPA also spoke with Licensee Eduardo “Eddie” Gonzalez, Jr. via phone, during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/22/2023). The LIC624 described Client #1 (C1) not receiving their prescribed medications on the evening of 08/21/2023. [See LIC 811 Confidential Names List for a description of C1.]

During today’s visit, LPA briefly toured the facility and performed a welfare check on C1 and their housemate, finding both clients were safe. LPA interviewed C1 and relevant staff and reviewed pertinent care records.

Interviews and records showed: On 08/20/2023, C1 departed the facility with a trusted family member, and facility staff endorsed C1’s medicines over to that person. During the late evening of 08/21/2023, a different family member brought C1 back to the facility and they handed C1’s medications back to staff. Facility staff subsequently performed an audit of C1’s returned medications and discovered that C1 did not receive multiple of their evening medications on 08/21/2023. C1 not suffer any observable negative health consequence from this incident.

CCLD determined that that C1 was not under Licensee’s direct care and supervision when the incident occurred. Licensee was not culpable for the medication errors. No deficiencies were cited for the above incident. Also, no deficiencies were observed or cited during today’s visit.

An exit interview was conducted with Suarez. A copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to the licensee during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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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