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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600906
Report Date: 01/26/2024
Date Signed: 01/28/2024 04:28:07 PM

Document Has Been Signed on 01/28/2024 04:28 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:WHITE, MRS. PATRICIA M.FACILITY NUMBER:
374600906
ADMINISTRATOR:PATRICIA M. WHITEFACILITY TYPE:
735
ADDRESS:12222 WINTER GARDENS DRIVETELEPHONE:
(619) 443-6075
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 3CENSUS: 2DATE:
01/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee Patricia WhiteTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPA) Liliana Silveira conducted an unannounced visit to continue a Required Annual Inspection which began on 01/09/2024. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee Patricia White.

During today’s visit, LPA continued the Annual Inspection. LPA and Licensee toured the interior and exterior of the facility. LPA also reviewed staff and resident records which contained the required documents. Confidential records were stored in locked areas. The Administrator also presented proof of current business liability insurance and surety bond.

Client bedrooms contained required furniture. Where tested, hot water temperature at taps (which were used by residents for personal care) were compliant: Bathroom #1 sink was 105.1 F and Bathroom #2 sink was 105 F. The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The refrigerator’s temperature was compliant at 40 F, and the freezer’s temperature was complaint at 0 F. The facility’s ambient internal temperature was compliant at 68 F.


No deficiencies were observed or cited during today's annual inspection. LPA requested Licensee Patricia
to submit a current Emergency Disaster Plan LIC 610-E/D, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms were provided to Licensee at the facility.


An exit interview was conducted with Patricia, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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