370808482-5-15-2023-08-AS-ARAZ-CRUP46-20230515105837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370808482
Report Date: 05/15/2023
Date Signed: 05/15/2023 10:58:45 AM

Document Has Been Signed on 05/15/2023 10:58 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	DSC - VILLAGE HOUSE		FACILITY NUMBER:	370808482
ADMINISTRATOR:	KRISTEN HOLLOBAUGH		FACILITY TYPE:	735
ADDRESS:	6010 HOWELL		TELEPHONE:	(619) 697-1611
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY: 6		CENSUS: 5	DATE:	05/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:			TIME COMPLETED:	11:30 AM

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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with caregiver Maria Vega. Administrator Kristen Hollobaugh, later arrived to meet with LPA to provide a tour of the facility. Inspection was concluded with Director of Consumer Services Diane Spurgon.

According to the facility’s license, the facility has a maximum capacity of six (6) clients of which all must be ambulatory. During today’s inspection, there were a total of five (5) clients in care, all of whom are ambulatory.

LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, 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 client activities. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 119 F, bathroom #1 sink was 118F, bathroom #2 sink was 118 F, and bathroom #3 was 118 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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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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: DSC - VILLAGE HOUSE	FACILITY NUMBER: 370808482
	VISIT DATE: 05/15/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

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

An exit interview was conducted with Spurgon, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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