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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601258
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:36:27 PM

Document Has Been Signed on 09/09/2024 03:36 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:FAIRWINDS - IVEY RANCHFACILITY NUMBER:
374601258
ADMINISTRATOR/
DIRECTOR:		SOMMER, JESSICAFACILITY TYPE:
740
ADDRESS:4490 MESA DRTELEPHONE:
(760) 439-8090
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 200CENSUS: 167DATE:
09/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:General Manager Karl MillerTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct follow up regarding a self-reported incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Karl Miller.

On 9/3/2024, the Department received an incident report and SOC341 Report of Suspected Dependent Adult/Elder Abuse from the facility that described an incident in which Resident 1 (R1) reported missing medication to facility staff. [General Manager was provided with LIC811 Confidential Names List to identify R1] Per incident report, facility management conducted a check of R1's room and interviewed R1 and relevant staff. Facility staff notified R1's responsible party. No injuries or adverse reactions were reported.

During today’s visit, LPA conducted a health and safety check, observed residents in care, reviewed facility records, interviewed Resident 1. Further follow-up is necessary.

No deficiencies were cited on today’s date. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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