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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004561
Report Date: 09/30/2024
Date Signed: 09/30/2024 03:32:04 PM

Document Has Been Signed on 09/30/2024 03:32 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MAILE ALOHAFACILITY NUMBER:
372004561
ADMINISTRATOR/
DIRECTOR:
PEREZ, JOSEPHINE A.FACILITY TYPE:
740
ADDRESS:3636 CHRISTINE STREETTELEPHONE:
(858) 274-0921
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 12CENSUS: 9DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Iren Crieghton TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA was welcomed by Caregiver Mercela Becerra and granted entry to the facility. Administrator Iren Creighton arrived during the visit and assisted the LPA. The facility was licensed for a capacity of twelve (12) residents, of which six (6) could be non-ambulatory. The facility also had a hospice waiver approved for two (2) residents.

The LPA conducted a tour of the facility accompanied by the administrator. The LPA observed the facility was undergoing a remodel. The facility was clean, and sanitary. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens as well as Personal Protective Equipment were observed. The facility had sufficient space and
equipment to facilitate dining, laundry, visitation, meetings, and client activities.

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 toxic chemicals/poisons accessible to clients.
Medications were labeled and stored in a locked area.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, a facility telephone and fire extinguishers were present.

A review of records was initiated, but due to time constraints, an additional visit on a subsequent day is necessary to complete the review and the annual inspection.

An exit interview was conducted with Administrator Creighton, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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