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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881506
Report Date: 02/02/2024
Date Signed: 02/02/2024 11:17:46 AM


Document Has Been Signed on 02/02/2024 11:17 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:CHAMPINE MANORFACILITY NUMBER:
371881506
ADMINISTRATOR:AUSTRIA, VIRNA LIZA R.FACILITY TYPE:
740
ADDRESS:1725 TOBACCO ROADTELEPHONE:
(858) 705-9696
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 6DATE:
02/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Bernadette Austria, Applicant
Virna Austria, Applicant		TIME COMPLETED:
11:25 AM
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On 2/2/2024, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an announced pre-licensing inspection at the facility. LPA Nwogene met with Applicants, Bernadette Austria and Virna Austria and toured the facility. There are currently six (6) residents in care due to a change of ownership.

Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for four (4) ambulatory and two (2) non-ambulatory residents.

Buildings and Grounds: The home is composed of Livingroom, kitchen, dining room, six (6) clients bedrooms, 2 resident restrooms, a staff bathroom/ laundry room, and backyard. 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 are no pools or other bodies of water located at the home. According to Bernadette and Virna, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished, and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathrooms were observed to have non-slip floors available. The hot water was tested and measured at 137 degrees Fahrenheit which is above regulatory limits. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order. Central heating and air conditioning system installed with a central panel located in hallway to control entire house.

Storage and Supplies: Medications will be stored in a locked cabinet in the dining room, 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 the laundry room, inaccessible to clients. A Fire extinguisher was available and fully charged.

CONTINUE ON LIC809-C

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHAMPINE MANOR
FACILITY NUMBER: 371881506
VISIT DATE: 02/02/2024
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CONTINUED FROM LIC809

Activities: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with a covered patio to provide shade over the outside table and chairs. Activity supplies are present inside the home, including television, magazines, and games.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked kitchen cabinet, available only to authorized individuals. Trash cans have tight-fitting lid. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge and freezer are large enough to accommodate required perishable foods.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, rights of resident council, a Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.



Missing Items:
  • Hot water temperature (105 -120 degrees F).
  • Night lights.
  • Fireplace and open-faced heater Covered.

LPA Nwogene will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure when proof of the missing items has been received.

An exit interview was conducted were this report was discussed with and provided to Bernadette Austria and Virna Austria.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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