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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604690
Report Date: 11/13/2023
Date Signed: 11/13/2023 11:18:19 AM


Document Has Been Signed on 11/13/2023 11:18 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:CARROLL'S RESIDENTIAL CAREFACILITY NUMBER:
374604690
ADMINISTRATOR:MEYERS, BRYANFACILITY TYPE:
740
ADDRESS:655 S MOLLISON AVETELEPHONE:
(619) 444-3181
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:144CENSUS: 125DATE:
11/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Sarita Mendoza, Assistant ManagerTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing.  LPA met with Sarita Mendoza, Assistant Manager, and discussed the purpose of the visit.

On 11/06/23, at approximately 5:00 PM,  staff was alerted to an emergency situation involving Resident 1 (R1) Staff heard R1 exhibiting signs of choking. Immediate life-support protocols were initiated, and the Heimlich maneuver was attempted to relieve the obstruction. Staff 2 promptly called emergency medical services (EMS) and Staff 1 and Staff 3 continued their efforts to clear the airway obstruction until the arrival of the EMS team.

During today’s visit, LPA performed a brief facility tour and welfare check on residents, finding that they were safe and alert. LPA also reviewed pertinent care records and interviewed relevant staff. Based on evidence, circumstances, and context obtained through reviewed records and interviews, no deficiency was cited for the above incident. Also, no deficiency was observed during today’s site visit.

An exit interview was conducted with Sarita Mendoza, Assistant Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Assistant Manager and her signature on this report confirms receipt of the Licensee Rights
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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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