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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804165
Report Date: 02/15/2024
Date Signed: 02/15/2024 05:30:25 PM


Document Has Been Signed on 02/15/2024 05:30 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
SO. CAL AC/SC, 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: 6DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Angelita Sanchez, AdministratorTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. LPA welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver, Erminda Aquino. Administrator, Angelita Sanchez, later joined LPA for the remainder of the inspection.

Per the license, the facility is approved to serve six (6) non-ambulatory elderly residents, over the age of sixty (60). On the day of the inspection six (6) of six (6) residents were present.

During the inspection, LPA toured the interior and exterior of the facility and observed each resident’s room. The facility was organized, kempt and in good repair. Pathways inside the property were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There was at least two days of perishable food, and at least seven days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas.

No pools or bodies of water were observed on the premises. Per Administrator, there are no firearms or ammunition kept at the facility. Carbon monoxide detectors, smoke alarms, emergency lighting, and telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed residents and reviewed staff and resident records/files. LPA interviews did not raise any licensing concerns.Confidential records were stored in locked areas.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GOOD SAMARITAN BOARD AND CARE FACILITY
FACILITY NUMBER: 370804165
VISIT DATE: 02/15/2024
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Continued: LIC809

LPA provided the Administrator with consultation and LIC9282 template for Infection Control Plans. LPA provided consultation and technical advisories for the following: Physical Plant/Environmental Safety, First Aid/CPR certification renewal, Administrator Certification renewal, and Resident Needs and Services Plans.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Administrator, Sanchez to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5