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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800142
Report Date: 12/28/2023
Date Signed: 12/28/2023 11:23:15 AM


Document Has Been Signed on 12/28/2023 11:23 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:CASA DE FLORESFACILITY NUMBER:
405800142
ADMINISTRATOR:JONATHAN D. ROBERTSFACILITY TYPE:
741
ADDRESS:1405 TERESA DRIVETELEPHONE:
(805) 772-7372
CITY:MORRO BAYSTATE: CAZIP CODE:
93442
CAPACITY:120CENSUS: DATE:
12/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jonathan Roberts, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) De Leon conducted a follow-up Case Management-Incident visit to the facility above. LPA met with Administrator Jonathan Roberts and explained the purpose of the visit.

On 12/26/2023 LPA Olson conducted the initial visit to the facility to follow up on a self reported incident by the facility. LPA Olson collected the following records: Staff Roster, Staff Schedules, R1's LIC 602A Physicians Report, R1's incident reports for 2023, R1's Preplacement Appraisal, R1's Appraisal Needs and Services Plan, R1's Care plan, R1's Admission Agreement, R1's discharge paperwork from Hospital visit on 12/21/2023.

LPA's reviewed records and according to R1's LIC 602A Physicians report had no history of suicide/self-harm or depression. According to R1's Care Plan, R1 was an assisted living resident admitted on 08/04/2023 was independent and only had a care plan to assist with medication management, R1 did not need assistance with any other ADL's. R1's death had no indication of neglect or lack of care and supervision by facility. Based on the the evidence the facility is not culpable for R1's death.

Facility submitted incident and death reports for R1 to Community Care Licensing (CCL). Facility contacted the following agencies to report the incident CCL, Law Enforcement and Long Term Care Ombudsman (LTCO).

Exit interview and copy of report printed for Administrator.


SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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