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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604065
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:37:15 PM

Document Has Been Signed on 03/22/2022 02:37 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:LAGUNA ESTATES SENIOR LIVINGFACILITY NUMBER:
374604065
ADMINISTRATOR:DONELLE WILLIAMSFACILITY TYPE:
740
ADDRESS:1088 LAGUNA DRIVETELEPHONE:
(760) 434-7116
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 214CENSUS: 0DATE:
03/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Donelle WilliamsTIME COMPLETED:
11:06 AM
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Licensing Program Analyst (LPA) Ramon Serrano conducted an announced Case Management visit to inspect the newly constructed memory care building approved for bedridden and non-ambulatory residents. LPA met with Executive Director Donelle Williams and we discussed the purpose of the visit.

On 8/9/21 the licensee submitted an application (LIC 200), Facility Sketch (LIC 999) and Local Fire Inspection Authority Information (LIC 9054), to request an approval for eight bedridden rooms and all other rooms for non-ambulatory use.

All required documentation was submitted for review, and the Carlsbad Fire Department conducted a Fire Clearance inspection on 1/26/22.

LPA inspected all rooms on the facility sketch (LIC999), that accompanied the STD850, Fire Safety Inspection Request, and no issues were observed or noted.

This portion of the application process is complete, and will be forwarded to management for final review and approval. The Licensee will then be notified of management approval by phone and the new license will be mailed to the Licensee.

No deficiencies cited during today's visit. An exit interview was conducted with Donelle Williams, The Licensee will be provided a copy of this report, along with their appeal rights (LIC9058 01/16) via email, and an electronic read receipt will serve as confirmation of receipt of documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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