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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600950
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:42:41 PM

Document Has Been Signed on 05/10/2024 12:42 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:GOOD SAMARITAN RETIREMENT HOMEFACILITY NUMBER:
374600950
ADMINISTRATOR/
DIRECTOR:
SUSAN SORENSENFACILITY TYPE:
740
ADDRESS:1515 JAMACHA WAYTELEPHONE:
(619) 590-1515
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 70CENSUS: 52DATE:
05/10/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:50 AM
MET WITH:Business Manager Vicky MammoTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Iby Strong conducted a Case Management visit regarding an application for increase in capacity. LPA identified herself to and discussed the purpose of the visit with Business Manager Vicky Mammo. Administrator Susan Sorensen arrived after.

Licensee applied for an increase in capacity from 70 to 110 residents, as the facility added a new build on the premises to hold a locked memory care unit (Building B). Fire Clearance was approved on April 4, 2024, for a total capacity of 110, all whom may be non-ambulatory of which 20 may be bedridden. The Fire Clearance also included locked perimeter/delayed egress for Building B only. LPA Strong spoke with Fire Inspector Lyons by telephone to verify information.

During the tour, LPA observed the physical plant and residents' accommodations, Building B is currently vacant, but holds required furnishings for future residents. Resident bathrooms are equipped with hand rails and non-slip material; locked medication rooms are present; sufficient space to conduct activities is available; facility posting requirements were present in a common area; laundry service is available; the facility administrators certification is current; no pool or other body of water is present on the facility grounds; per the Administrator there are no guns, weapons or ammunition located on the property. LPA and Administrator discussed continuing operation requirements, record keeping and physical plant compliance.

No deficiencies were issued during this visit.

An exit interview was conducted with Administrator, to whom a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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