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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604717
Report Date: 07/22/2024
Date Signed: 07/22/2024 11:25:14 AM

Document Has Been Signed on 07/22/2024 11:25 AM - 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:HACIENDA MISSION SAN LUIS REY, THEFACILITY NUMBER:
374604717
ADMINISTRATOR/
DIRECTOR:
BUHLE, DIANEFACILITY TYPE:
740
ADDRESS:4000 MISSION AVETELEPHONE:
(520) 797-4000
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 294CENSUS: 263DATE:
07/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Business Office Manager Kristine GutierrezTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct follow up regarding an elopement. LPA was greeted by, identified herself to, and explained the purpose of the visit with Business Office Manager Kristine Gutierrez.

On 6/26/2024, the Department received a self-reported incident report that described an elopement that occurred on 6/25/2024. The incident report stated that Resident 1 (R1) had eloped from the facility and was found by law enforcement and had sustained injuries in the process of the elopement. The facility was notified of R1's elopement by law enforcement and sent staff to escort R1 to the hospital to receive medical treatment for R1's injuries. Facility staff notified R1's responsible party of the elopement. R1 returned to the facility on 6/27/2024.

During today’s visit, LPA conducted a health and safety check, observed residents in care, reviewed facility records, and interviewed staff. R1 moved out of the community on 7/12/2024 and was not present during LPA's visit. LPA did not observe any health or safety concerns during the visit. At this time, additional follow-up is needed.

No deficiencies were cited on today’s date. An exit interview was conducted with Business Office Manager Kristine Gutierrez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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