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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604722
Report Date: 08/09/2024
Date Signed: 08/09/2024 02:52:29 PM


Document Has Been Signed on 08/09/2024 02:52 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:NOVELLUS CLAIREMONT LLCFACILITY NUMBER:
374604722
ADMINISTRATOR:LAIRD, CANDIFACILITY TYPE:
740
ADDRESS:5219 CLAIREMONT MESA BLVD.TELEPHONE:
(858) 292-8044
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:214CENSUS: 77DATE:
08/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director Emily De La BarreTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA identified himself and disclosed the purpose of the visit to Executive Director Emily De La Barre.

Today’s visit was in response to an Unusual Incident Report (LIC 624) received by the Department on 08/09/2024. The LIC 624 noted Resident # 1 (R1) had a fall and sustained a fracture. During the visit, the LPA secured pertinent records and conducted a tour of the facility. There was no immediate health, nor safety concerns observed. At this time, additional visits and follow up telephone calls may be necessary.

An exit interview was conducted with Executive Director De La Barre. A copy of this report, LIC 811, and Licensee/Appeal Rights (LIC 9058) were provided to De La Barre via email. An email read receipt confirms the documents were received by De La Barre.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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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