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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603836
Report Date: 06/09/2022
Date Signed: 06/09/2022 02:38:22 PM

Document Has Been Signed on 06/09/2022 02:38 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:SENIORS DIGNITY HOME AND CAREFACILITY NUMBER:
374603836
ADMINISTRATOR:ALOZIE, EDWARDFACILITY TYPE:
740
ADDRESS:966 BOLLENBACHER STREETTELEPHONE:
(619) 957-6133
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: 6DATE:
06/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Edward Alozie, LicenseeTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit at the facility. LPA Lopez identified herself and was granted entry by Chioma Alozie, caregiver. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Edward Alozie, Licensee.

The facility self-reported an incident regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing on May 29, 2022. The facility reported that on May 26, 2022, R1 had an accidental injury.

During today’s visit, LPA briefly toured the facility, conducted interviews with staff and resident, and requested and obtained resident records. This case management needs further follow-up. No deficiencies were cited during this visit. LPA went over Title 22, Section 87468.1(a) (16) Personal Rights of Residents in All Facilities.

An exit interview was conducted with Licensee Alozie and a copy of this report, LIC 811 and Applicant/Licensee Rights (LIC 9058 01/16) were provided to Licensee at the conclusion of the visit. The signature below confirms the receipt of the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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