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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604722
Report Date: 01/02/2025
Date Signed: 01/03/2025 09:03:40 AM

Document Has Been Signed on 01/03/2025 09:03 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:NOVELLUS CLAIREMONT LLCFACILITY NUMBER:
374604722
ADMINISTRATOR/
DIRECTOR:
LAIRD, CANDIFACILITY TYPE:
740
ADDRESS:5219 CLAIREMONT MESA BLVD.TELEPHONE:
(858) 292-8044
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 214TOTAL ENROLLED CHILDREN: 0CENSUS: 82DATE:
01/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Executive Director Emily DeLaBarreTIME VISIT/
INSPECTION COMPLETED:
01:30 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 DeLaBarre.

On 12/09/2024, the Department received an incident report indicating Resident # 1 (R1) had sustained a fall that was not witnessed, on 12/05/2024. R1 initially declined having pain, but later reported pain and was transported to the hospital. R1 was discharged with not fractures. On 12/12/2024, R1 reported excruciating pain and was transported to the hospital and diagnosed with a pelvic fracture.

Review of records revealed R1 had a CT scan and several X-ray exams preformed during R1's hospital visit on 12/05/2024. These exams did not reveal any fractures and R1 was discharged back to the facility. Per interview with Executive Director DeLaBarre, R1 did not sustain any additional falls between 12/05/2024 and 12/12/2024. At this time,R1 is still at the hospital receiving treatment. Additional visits and review of additional pending records is necessary.

An exit interview was conducted with Executive Director DeLaBarre, to whom a copy of this report, and Licensee/Appeal Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received.

Lizzette TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301
DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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