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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604786
Report Date: 08/15/2024
Date Signed: 08/16/2024 04:07:56 PM


Document Has Been Signed on 08/16/2024 04:07 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:THRIVE ELDER CAREFACILITY NUMBER:
374604786
ADMINISTRATOR:ENGDAW, AMSALFACILITY TYPE:
740
ADDRESS:4670 TWAIN AVE.TELEPHONE:
(619) 757-9519
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:6CENSUS: 1DATE:
08/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver Juliet RemullaTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Debbie Correia, conducted an unannounced Case Management visit to the facility. LPA Correia was met at the entry by Caregiver Juliet Remulla, identified herself and was granted entry. Licensee Amsal Engdaw arrived a short time later, to whom LPA explained the purpose of the visit.

Today's visit was to confirm the details of a self-reported death report received by CCLD San Diego Regional Office on August 14, 2024. During today's visit LPA interviewed staff and conducted a review of and secured resident records. [See LIC 811 Confidential Names]

No deficiencies were cited during today's visit. An exit interview was conducted with Licensee Engdaw to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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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