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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601939
Report Date: 12/23/2024
Date Signed: 12/23/2024 05:05:46 PM

Document Has Been Signed on 12/23/2024 05:05 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:SPECIAL FRIENDS-SAGEWOODFACILITY NUMBER:
374601939
ADMINISTRATOR/
DIRECTOR:
WOJCIECHOWSKI, MICHELLEFACILITY TYPE:
735
ADDRESS:13411 SAGEWOOD DRIVETELEPHONE:
(858) 312-1687
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 5DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:House Manager, Ramily HernandezTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Roman and Sabel Martinez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with House Manager, Ramily Hernandez. According to the facility’s license, the facility has a maximum capacity of 6 ambulatory developmentally disabled adults ages 18-59.

LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to client. Medications were labeled, as required, and stored in locked areas. Water temperature was measured at 137 degrees F.

One pool/bodies of water is located in the back yard of the premises fenced with 5 foot fence and locked. Per Ramily Hernandez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present readily accessible with an inspection date of 08/30/24. First aid kit(s) were complete and readily accessible.

Due to time constraints an additional visit on a subsequent day is necessary to complete the annual inspection. One deficiency was cited today for water temperature exceeding 120 degrees F. A plan of correction was jointly formulated with the house manager, Ramily Hernandez.

An exit interview was conducted with House Manager, Ramily Hernandez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22), LIC 809-D and LIC 9201 were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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Document Has Been Signed on 12/23/2024 05:05 PM - It Cannot Be Edited


Created By: David Roman On 12/23/2024 at 04:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SPECIAL FRIENDS-SAGEWOOD

FACILITY NUMBER: 374601939

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 faucet and 1 shower out of 3 bathrooms, which posed a potential health, safety or personal rights risk to 2 persons in care.
POC Due Date: 01/06/2025
Plan of Correction
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House Manager agreed to submit a maintenance request to have water temperatures set between 105 and 120 degrees F. House Manager agreed to send communication to LPA that the water temperature was changed. House Manager also agreed to label the faucets that are delivering hot water with warninig signs.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:David Roman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
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