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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004808
Report Date: 05/13/2024
Date Signed: 05/13/2024 02:13:39 PM


Document Has Been Signed on 05/13/2024 02:13 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:MISSION HOMEFACILITY NUMBER:
372004808
ADMINISTRATOR:JOHN CURMAKFACILITY TYPE:
740
ADDRESS:2996 MISSION VILLAGE DR.TELEPHONE:
(858) 569-8867
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:6CENSUS: 6DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lidia Leo, CaregiverTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Lidia Leo, Caregiver. According to the facility’s license, the facility serves six (6) non-ambulatory elderly residents, age 60 and above. On the day of the inspection, there were five (5) ambulatory residents present.

LPA toured the interior and exterior of the facility and inspected each resident’s room. The facility was organized, kempt, in good repair and contained no offensive odors. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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 resident activities.

There was at least two days of perishable food, and at least seven 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, as required, and stored in locked areas.

No pools or bodies of water were observed on the premises. Per Caregiver, Leo, no firearms, or ammunition are kept at the facility. Emergency lighting, and facility telephone were operational. Fire extinguisher(s) were present. A first aid kit was observed and readily accessible. Required licensing postings were observed in visible areas of the facility. Hot water temperatures measured in the resident restroom and kitchen recorded at 103.8 and 109.8 degrees, F and within Title 22 Regulations.

LPA reviewed staff and resident records/files. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. The facility certificate of liability insurance was current and possessed the required coverages.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MISSION HOME
FACILITY NUMBER: 372004808
VISIT DATE: 05/13/2024
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[CONTINUED FROM LIC 809]


LPA provided consultation and training on carbon monoxide and smoke detectors. No deficiencies were noted, and no citations were given.

An exit interview was conducted with Caregiver, Leo to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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