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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604505
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:39:26 PM

Document Has Been Signed on 03/07/2023 04:39 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:UC SENIOR CARE IVFACILITY NUMBER:
374604505
ADMINISTRATOR:KELLY, FLORAFACILITY TYPE:
740
ADDRESS:3810 GOVERNOR DRIVETELEPHONE:
(858) 583-6431
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY: 6CENSUS: 6DATE:
03/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee Flora KellyTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Caregiver Pilar Moreno. LPA then met and discussed the purpose of the visit with licensee Flora Kelly.

Today's visit was in response to an LIC624 Unusual Incident/Injury Report, which licensee self-submitted to the CCLD San Diego Regional Office on 02/27/2023, involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed facility tour / welfare check, collected records, interviewed R1 and staff, and provided technical assistance to the licensee. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Kelly, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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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