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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881376
Report Date: 01/23/2023
Date Signed: 01/23/2023 12:00:02 PM


Document Has Been Signed on 01/23/2023 12:00 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ESCONDIDO RETIREMENT GARDENFACILITY NUMBER:
371881376
ADMINISTRATOR:WILLIAM, MERCELITAFACILITY TYPE:
740
ADDRESS:819 N. ROSE STREETTELEPHONE:
(760) 294-4433
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 0DATE:
01/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:ADMINISTRATOR, MARCELITA WILLIAMS.TIME COMPLETED:
12:06 PM
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On January, 23, 2023, Licensing Program Analyst (LPA), Venus Mixson conducted a scheduled visit to complete a Pre-licensing inspection. LPA Mixson met with Administrator introduced self and stated the purpose of the visit. LPA Mixson toured the facility inside and outside. The facility is a single story home with five bedrooms, two baths, kitchen, dinning area, and living room, with a 2 car garage. LPA Mixson observed sufficient food supply, and the overall facility to be in clean condition with a comfortable temperature. LPA Mixson observed passageways to be free from obstruction. Water temperature was tested and found to be within regulation limitations. There were grab bars and nonskid mats and/or strips in the bathrooms. LPA Mixson observed location where medications will be kept locked and inaccessible. LPA observed smoke alarms in working condition, fire extinguishers charged and are operable carbon monoxide detector installed. The Escondido Fire Department cleared facility on 12/28/2022, for 3 Ambulatory, two Non-Ambulatory, and 1 Bedridden. LPA Mixson observed the facility is equipped with lights in the passages. The facility is also stocked with emergency night lights throughout the home. LPA observed locked cleaning supplies and the sharps are locked in a kitchen drawer. All doors, and passageways are clear from obstruction. All beds have the required linen and supplies. There was enough clean linen and hygiene items. There was appropriate lighting in each room with night stand and chair. LPA Mixson observed central heating and air conditioning systems. The Administrator dialed the phone number (760) 294- 4433 it is operable. Outside/Yards: No obstructions or standing water observed. COMP III reviewed. An exit interview was conducted and a copy of this report was given to Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
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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