<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600476
Report Date: 04/18/2024
Date Signed: 04/18/2024 01:12:05 PM


Document Has Been Signed on 04/18/2024 01:12 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:TENENBAUM VILLAFACILITY NUMBER:
374600476
ADMINISTRATOR:STEVEN F. TENENBAUMFACILITY TYPE:
740
ADDRESS:3463 CIRCULO ADORNOTELEPHONE:
(760) 942-5048
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:8CENSUS: 2DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator Mutiawati TenenbaumTIME COMPLETED:
01:20 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) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Administrator Mutiawati Tenenbaum. The facility's license shows a maximum capacity of eight (8) non-ambulatory residents, eight (8) of whom may be bedridden.  During today’s inspection there were two (2) residents in care.
 
LPA and Administrator Mutiawati Tenenbaum toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair.  Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings.  Doors, windows, screens, 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 client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored.  Cooking, dining equipment, and utensils were present.  No toxic chemicals or poisons were accessible to clients.  Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Mutiawati Tenenbaum, no firearms or ammunition are kept at the facility.  Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order.  Fire extinguisher(s) were serviced within the last 12 months.  First aid kit(s) were complete and readily accessible.  Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients, and reviewed facility records.  The files reviewed by LPA contained required documents.  Confidential records were stored in locked areas.

No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Mutiawati Tenenbaum to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1