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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604632
Report Date: 09/20/2023
Date Signed: 09/20/2023 04:27:45 PM

Document Has Been Signed on 09/20/2023 04:27 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:LOVE FIRST RESIDENCES #1FACILITY NUMBER:
374604632
ADMINISTRATOR:O'CONNELL, MICHELLEFACILITY TYPE:
735
ADDRESS:1338 BOSWORTH STTELEPHONE:
(619) 312-5299
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 6CENSUS: 5DATE:
09/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Tania OzunaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Case Management - Incident visit. LPA was allowed entry by Direct Support Professional (DSP) Tania Ozuna, with whom LPA introduced herself and discussed the purpose of the visit.

Today's visit was in response to a Death Report (LIC624) which licensee submitted to CCLD San Diego Regional Office. The Death Report, received by CCLD on 09/20/2023 described Client 1's (C1) passing away on 09/18/2023. LIC624 and Special Incident Report were also received by CCLD on 9/20/2023.

During today's visit, LPA performed a brief tour of the facility and welfare check on clients present, finding no safety concerns.

According to facility records, C1 was admitted into the facility on 09/11/2017 with primary diagnoses of Mild Intellectual Disability, Down Syndrome, and Seizure Disorder. LPA interviewed staff present at the time of death. (See LIC811 Confidential Names List for a description of C1 and Staff 1, Staff 2, and Staff 3.)

No deficiencies were cited for C1's death. No other deficiencies were observed or cited during today's visit. LPA spoke with Licensee Denise Rose over the phone. LPA requested Licensee for a copy of the death certificate as soon as it is available. Licensee Rose acknowledged the request.

An exit interview was conducted with DSP Ozuna, to whom a copy of this report, LIC811 (Confidential Names List), and the Applicant/Licensee Rights (LIC9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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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