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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601939
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:13:26 PM

Document Has Been Signed on 02/14/2024 03:13 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SPECIAL FRIENDS-SAGEWOODFACILITY NUMBER:
374601939
ADMINISTRATOR:WOJCIECHOWSKI, MICHELLEFACILITY TYPE:
735
ADDRESS:13411 SAGEWOOD DRIVETELEPHONE:
(858) 312-1687
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Ramily Hernandez, Manager & Michelle Wojciechowski, AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Ramily Hernandez, House Manager. Michelle Wojciechowski later joined LPA for the remainder of the inspection.

The facility is approved and licensed to serve six (6) ambulatory developmentally disabled adults ages 18-59. On the day of the inspection none of the six (6) clients were present as they were at their day program.

During the inspection, LPA toured the interior and exterior of the facility and observed each client’s room. The facility was organized, kempt and in good repair. Pathways inside the property were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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.

There were at least two days of perishable food, and at least seven days of non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in lock areas.

LPA observed a swimming pool in the backyard. The pool was enclosed by a fence that was five feet high and had gates that swung away from the pool, self closed and self latched. Per Ms. Wojciechowski, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Hot water temperatures measured in the client restroom and kitchen recorded at 113.1 and 106.7, degrees Fahrenheit which are
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SPECIAL FRIENDS-SAGEWOOD
FACILITY NUMBER: 374601939
VISIT DATE: 02/14/2024
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both within Title 22 Regulations. LPA interviewed staff and reviewed staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained the required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Administrator Wojchiechowski, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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