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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372000641
Report Date: 10/31/2024
Date Signed: 10/31/2024 10:53:14 AM

Document Has Been Signed on 10/31/2024 10:53 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:WHITE SANDS LA JOLLAFACILITY NUMBER:
372000641
ADMINISTRATOR/
DIRECTOR:		SMART, SHELLYFACILITY TYPE:
741
ADDRESS:7450 OLIVETAS AVETELEPHONE:
(858) 454-4201
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY: 299CENSUS: 247DATE:
10/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Shelly Smart, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
10:12 AM
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Licensing Program Analyst (LPA), Tiffany Holmes conducted an unannounced case management visit. LPA Holmes introduced herself and was allowed entry into the facility and explained the purpose of the visit to Shelly Smart, Executive Director.

Today’s visit was regarding an incident report received on 09/04/2024 in the office. During today’s visit LPA toured the facility and observed and received pertinent documents. The incident involved Resident 2 (R2) yelling at Resident (R1) and tapping R1 on the leg somewhat aggressively in front of staff because R1 could not understand what R2 was telling them to do. Interviews revealed the two have been partners for over a year. LPA Holmes conducted interviews and the interviews did not reveal any health and safety concerns. Interviews revealed both residents are cognitively impaired and still declining. Staff interviews revealed there is a plan to keep both residents safe and that is a 24 hour caregiver that will report anything to the leadership staff. The 12 hour caregiver started on August 13, 2024 and on 08/21/2024 they moved it to the 24 hour caregiving which is what is still in place today. Interviews revealed both families know about the relationship and are okay with the relationship between R1 and R2. The families don't have any problems with the two residents being together. According to staff, they feel that it is a loving relationship and that R2 does get a little flustered with R1 but it is because of their decline as well. They both start their day with breakfast together and then R2 leaves the facility. They meet up for dinner and watch a movie and then retreat back to R1s room to sleep. This is their daily routine.
Based on todays visit, no deficiencies were observed or cited during todays visit
An exit interview was conducted with Shelly Smart, Executive Director. A copy of this report, and the Licensee/Appeal Rights (9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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