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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603328
Report Date: 01/02/2025
Date Signed: 01/02/2025 02:08:09 PM

Document Has Been Signed on 01/02/2025 02:08 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:ARBOR VICTORIAFACILITY NUMBER:
374603328
ADMINISTRATOR/
DIRECTOR:		RICHARD M AXTELLFACILITY TYPE:
740
ADDRESS:3410 HIGHLAND DRIVETELEPHONE:
(760) 729-4800
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 6CENSUS: 3DATE:
01/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Richard AxtellTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Case Management visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Richard Axtell.

Today's visit was in response to a self reported incident that occurred on 12/26/2024 regarding the death of Resident #1 (R1). [See LIC811 Confidential Names List.]

During today’s visit LPA conducted a brief facility tour, observed residents in care, and interviewed relevant staff. No deficiencies were cited during today’s visit.

An exit interview was conducted with Administrator Richard Axtell, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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