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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604575
Report Date: 05/17/2024
Date Signed: 05/17/2024 05:20:37 PM

Document Has Been Signed on 05/17/2024 05:20 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:UNIVERSAL HOMES IIFACILITY NUMBER:
374604575
ADMINISTRATOR/
DIRECTOR:		CRISOSTOMO, YOANNEFACILITY TYPE:
735
ADDRESS:2944 SANDOVER CTTELEPHONE:
(619) 632-3549
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY: 4CENSUS: 3DATE:
05/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator, Joanne ChrisostomoTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno made a Case Management visit to follow-up on a client's death. LPA was granted entry into the facility by Administrator, Joanne Chrisostomo, to whom she disclosed the purpose of the visit.

A Incident Report was received by Community Care Licensing (CCL) on May 16, 2024, informing that Client #1 (C1) [staff was provided an LIC 811 that identifies the client] passed away on May 16, 2024, at a skilled nursing facility after being discharged from the hospital. C1 had been admitted to the hospital on April 5, 2024 for weak respiration. According to information provided to CCL, the cause of death was chronic aspiration pneumonia.

During today's visit, LPA conducted a tour of the facility, obtained all relevant records for C1 and conducted interviews with staff.

No deficiencies were cited during today's visit.

An exit interview was conducted with Administrator, Chrisostomo, to whom a copy of this report, LIC 811 List of Confidential Names and the appeal rights (LIC9058 03/23), was provided at the end of the visit.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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