374603439-7-28-2025-08-AS-AGOH-DJZV68-20250728160907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603439
Report Date: 07/28/2025
Date Signed: 07/28/2025 04:09:10 PM

Document Has Been Signed on 07/28/2025 04:09 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:	CASA DE MANANA		FACILITY NUMBER:	374603439
ADMINISTRATOR/ DIRECTOR:	MARIVEL JOHNSON		FACILITY TYPE:	740
ADDRESS:	849 COAST BLVD		TELEPHONE:	(858) 454-2151
CITY:	LA JOLLA	STATE: CA	ZIP CODE:	92037
CAPACITY: 249		CENSUS: 219	DATE:	07/28/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:50 PM
MET WITH:	Director of Resident Services Coco Feng		TIME VISIT/ INSPECTION COMPLETED:	04:10 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) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on a series of incidents reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Director of Resident Services (DRS) Coco Feng. Within a 2 week period (July 7th-21st, 2025), Community Care Licensing received four (4) incident reports regarding three (3) separate resident falls, with one (1) resident falling twice within that period. That resident, (identified as R1) had an unwitnessed fall on 7/7/25 in their unit, resulting in a head injury requiring staples. R1 had another unwitnessed fall in their unit two (2) weeks later on 7/21/25, but sustained no acute injuries, per the report. The next resident (identified as R2) had an unwitnessed fall in the dining area on 7/15/25, resulting in an upper extremity fracture. The final resident (identified as R3) had a fall in their unit on 7/17/25 and it was reported to staff by R3's spouse. Per the report, R3 refused emergency transport and was driven by their spouse to the hospital where a hand fracture was discovered. Emergency services were contacted for R1's and R2's falls, and responsible parties and Primary Care Physicians (PCPs) were notified for R1, R2, and R3. During today's visit, LPA conducted file review, a health and safety visit with R1 and R3, and provided consultation with DRS Feng. LPA was informed that R2 remains out of the community at this time. R1 is an identified fall risk and file review and interviews revealed implementation of actions taken to reduce/mitigate risk. Initial fall encounter for R2 and R3. No Deficiencies were cited during the visit. An exit interview was conducted with Director of Resident Services Feng to whom a copy of this report was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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