371881337-9-28-2022-18-AS-STOS-CJPQ4K-20220928115029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881337
Report Date: 09/28/2022
Date Signed: 09/28/2022 11:50:44 AM

Document Has Been Signed on 09/28/2022 11:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PARTNERS IN SENIOR LIVING		FACILITY NUMBER:	371881337
ADMINISTRATOR:	TOMLINSON, BRENNA		FACILITY TYPE:	740
ADDRESS:	2657 CRISIE LANE		TELEPHONE:	(858) 261-4639
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Brenna Tomlinson, Applicant		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing inspection to the facility. The LPA met with Applicant, Brenna Tomlinson. Application: The application is for a Residential Care Facility for the Elderly (RCFE). The fire clearance has been granted for six (6) non-ambulatory residents. A Hospice Waiver has been granted for two (2). Buildings and Grounds: The home is composed of six (6) resident bedrooms,a separate staff living quarters, five (5) bathrooms, two living room spaces, kitchen and dinning areas, a front/back yard area (with seating), and laundry room. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There is no pool or other bodies of water located on the premises. According to Tomlinson, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are completely furnished and privacy is available. The dining and living room areas are clutter free and in good condition. Bathrooms were observed to have non-slip mats available. The hot water was tested and measured at 109.2 degrees Fahrenheit, which is within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order. Storage and Supplies: Activities were observed to be available and in sufficient amount for the requested census. Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a secured bin. Linens, towels, and other equipment are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged. Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARTNERS IN SENIOR LIVING	FACILITY NUMBER: 371881337
	VISIT DATE: 09/28/2022

NARRATIVE

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are in working order. Sharps will be stored in a locked kitchen pantry, available only to authorized individuals.

Forms: The following signs were observed to be available at the home: Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights/Non Discrimination policy, and Facility Sketch (LIC 999), and Complaint Information.

No follow ups are required at this time. The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with and a copy provided to Tomlinson.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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