<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004836
Report Date: 02/25/2022
Date Signed: 02/25/2022 04:45:02 PM

Document Has Been Signed on 02/25/2022 04:45 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:R & R RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
372004836
ADMINISTRATOR:REM RYAN REYESFACILITY TYPE:
740
ADDRESS:10255 THANKSGIVING LANETELEPHONE:
(858) 271-9349
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 5CENSUS: 4DATE:
02/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Administrator, Ryan ReyesTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA was greeted and allowed entry into the facility by staff, Emelita Garcia. LPA met with Administrator, Ryan Reyes and Licensee Rem Reyes.

During today's visit, LPA briefly toured the facility, obtained records and interviewed staff. On 02/25/22, Community Care Licensing received a self reported incident involving Resident #1 (R1). The incident report indicated on 02/22/22, staff heard a loud sound and rushed to R1's bedroom. R1 was observed on the floor. Staff contacted 911 and R1 was transported to the hospital for evaluation.

No deficiencies were observed during today’s visit. An exit interview was conducted, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Administrator via electronic mail. An electronic mail read receipt was requested to be provided upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1