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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601175
Report Date: 06/05/2024
Date Signed: 06/05/2024 11:10:14 AM

Document Has Been Signed on 06/05/2024 11:10 AM - 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:DSC, INC. - BUENA VALLEY HOUSEFACILITY NUMBER:
374601175
ADMINISTRATOR/
DIRECTOR:		DIANE SPURGEONFACILITY TYPE:
735
ADDRESS:1787 DUPONT DRIVETELEPHONE:
(619) 460-7333
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 3CENSUS: 0DATE:
06/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Kristen HollobaughTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Administrator Kristen Hollobaugh to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of three (3) ambulatory adult clients. During today’s earlier inspection, three (3) client were in care waiting for day program transport, which arrived around 9:10 am. During the time of the continuation inspection zero clients were present.

LPA, accompanied by care giver Marshell Gibson and Administrator Hollobaugh, 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’s ambient internal temperature was compliant at 70 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink, bathroom #1 and bathroom #2.

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 sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: DSC, INC. - BUENA VALLEY HOUSE
FACILITY NUMBER: 374601175
VISIT DATE: 06/05/2024
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CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Kristen Hollobaugh, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and was unable to interview clients however, LPA observed clients and they appeared to be safe, well groomed, healthy and continent in the environment. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Client and resident files contained all required documents.

No deficiencies were cited or observed on this date.


An exit interview was conducted with Administrator Kristen Hollobaugh, A copy of this report and appeal rights (LIC9056 01/16), were provided via hardcopy at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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