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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804165
Report Date: 10/08/2020
Date Signed: 10/08/2020 11:55:47 AM

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:GOOD SAMARITAN BOARD AND CARE FACILITYFACILITY NUMBER:
370804165
ADMINISTRATOR:FAYE MAYOFACILITY TYPE:
740
ADDRESS:6255 MCHANEY COURTTELEPHONE:
(619) 267-2445
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 5DATE:
10/08/2020
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Angelita Sanchez, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Daniel Pena conducted an announced Post licensing Tele-visit due to COVID-19. LPA identified himself to the Licensee/Administrator, Angelita Sanchez and discussed the purpose of the visit which was a Pre-licensing Inspection to process the Licensee’s application for a Change of Non-Ambulatory capacity. The original license allowed the licensee to serve elderly clients, ages 60 and over, one (1) of whom may be non-ambulatory in Room #2. The licensee is requesting to serve six (6) non-ambulatory residents.

A Change of Non-Ambulatory capacity application was received by Community Care Licensing (CCL) on February 27, 2020, in which the licensee requested an increase of non-ambulatory residents from one (1) to six (6) residents. The Fire Safety Inspection Request, dated March 4, 2020, was approved by the local fire authority on September 20, 2020. The approval was received by Community Care Licensing on September 28, 2020.
During today's tele-visit, LPA conducted a tour of the facility and no immediate health and/or safety concerns were observed.

During the virtual tour it was determined that the facility sketch/floor plan was inconsistent with the current layout of the facility. A follow up tele-visit will be scheduled once the floor plan is revised and reviewed by CCLD.

An exit interview was conducted with Mrs. Sanchez. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to her via email.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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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