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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604532
Report Date: 09/22/2023
Date Signed: 09/22/2023 09:54:14 AM

Document Has Been Signed on 09/22/2023 09:54 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ROJA HOUSEFACILITY NUMBER:
374604532
ADMINISTRATOR:GILBO, JACKELINEFACILITY TYPE:
735
ADDRESS:4944 ROJA DRIVETELEPHONE:
(760) 500-8541
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 4DATE:
09/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Jackie GilboTIME COMPLETED:
10:14 AM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with administrator Jackie Gilbo.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 9/18/2023). According to the LIC624: on 9/182023, Client #1 (C1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] C1 returned to the facility unharmed on 9/17/2023.

During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed C1 and staff.

According to C1’s latest LIC602 Physician’s Report (6/2/2023) their doctor determined that C1 is not able to safely leave the facility unassisted. Interviews and records showed that Licensee had a written Absentee Notification Plan as part of C1’s record of care, and that staff followed this plan.

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

An exit interview was conducted with administrator, 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: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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