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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604503
Report Date: 01/18/2024
Date Signed: 01/18/2024 04:52:26 PM

Document Has Been Signed on 01/18/2024 04:52 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:MORNINGSIDE MANORFACILITY NUMBER:
374604503
ADMINISTRATOR:REGINA JACKSON-PATTONFACILITY TYPE:
740
ADDRESS:2847 MORNINGSIDE ST.TELEPHONE:
(619) 856-4968
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 6CENSUS: 4DATE:
01/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Regina Jackson- Patton,
Administrator		TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced case management visit. LPA identified herself and was granted entry by the Administrator. LPA met with Regina Jackson- Patton, Administrator and discussed the purpose of the visit.

On January 16, 2024 the facility self reported a resident death regarding Resident 1 (R1) from January. 12, 2024 to Community Care Licensing. This visit was conducted to follow-up with the death report.

During today’s visit, LPA briefly toured the facility, conducted interviews with Regina Jackson- Patton, Administrator, requested and obtained relevant records. A copy of the resident's death certificate was requested upon receipt. No deficiencies were cited during today’s visit.

An exit interview was conducted with Regina Jackson- Patton, Administrator and a copy of this report, and Licensee/Appeal Rights (LIC 9058 01/16) were provided to both Managers at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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