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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604546
Report Date: 10/17/2024
Date Signed: 10/17/2024 04:43:15 PM

Document Has Been Signed on 10/17/2024 04:43 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:ACORN OAKS MANOR IFACILITY NUMBER:
374604546
ADMINISTRATOR/
DIRECTOR:		LIMPIN, ALEXANDERFACILITY TYPE:
740
ADDRESS:6207 ACORN STTELEPHONE:
(619) 777-9674
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 6CENSUS: 4DATE:
10/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:House Manager Jamily Hallak TIME VISIT/
INSPECTION COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to and discussed the purpose of the visit with House Manager Jamily Hallak.

Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 10/15/2024. [See LIC 811 Confidential Names List for a description of (R1]. Per the report, (R1) passed away on 10/08/2024.

During today’s visit, LPA performed a brief facility tour and welfare check on remaining clients, finding no safety concerns. LPA also collected copies of and reviewed pertinent records, and interviewed relevant staff.

No deficiencies were observed or cited during today’s visit.

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

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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