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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800142
Report Date: 12/26/2023
Date Signed: 12/26/2023 04:47:42 PM


Document Has Been Signed on 12/26/2023 04:47 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
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: 80DATE:
12/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Jonathan Roberts, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jenny Olson conducted an unannounced Case Management - Incident inspection. At 2:27 p.m., LPA met with Administrator Jonathan Roberts and explained the reason for the visit.
The reason for today's inspection is to follow up on a self-reported incident report received via email on 12/25/2023. The report pertains to Resident #1 (R1) found deceased from a suspected suicide. An interview was conducted with the Administrator. The LPA also reviewed records and obtained copies of pertinent documents.

No immediate health and safety concerns were observed during today's inspection.

Further investigation is needed. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB).

Exit interview conducted, copy of the report was emailed and printed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
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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