374602563-10-2-2024-08-AS-CLOZ-D9P5BC-20241002194832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602563
Report Date: 10/02/2024
Date Signed: 10/02/2024 07:49:29 PM

Document Has Been Signed on 10/02/2024 07:49 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:	PEARLS COVE		FACILITY NUMBER:	374602563
ADMINISTRATOR/ DIRECTOR:	AERIAKA JACOBS		FACILITY TYPE:	735
ADDRESS:	5899 TOOLEY STREET		TELEPHONE:	(619) 266-0752
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY: 4		CENSUS: 4	DATE:	10/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Aeriaka Jacobs, Licensee and Diane Diaz, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Licensee Aeriaka Jacobs and Administrator Diana Diaz. LPA discussed the purpose of the visit with Administrator Diaz and Licensee Jacobs. According to the facility’s license, there may be a maximum of four (4) clients, one of whom may be non-ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 4 clients living at the facility. There were 4 clients present at the facility site during the inspection. LPA, accompanied by Administrator Diaz, 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, 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 activities. The facility’s ambient internal temperature was comfortable and compliant, at 71 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink was compliant and measured hot water at 105 degrees F; sink in restroom #1 delivered hot water at 105.6 degrees F; sink in restroom #2 delivered hot water at 105.1 degrees F; and sink in restroom #3 delivered hot water at 105.1 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking and dining equipment and utensils were present, and all safely stored. There were no toxic chemicals or poisons accessible to clients. Medications were properly labeled, as required, and stored in locked cabinet which LPA inspected. The facility-maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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: PEARLS COVE	FACILITY NUMBER: 374602563
	VISIT DATE: 10/02/2024

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per administrator Diaz, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present (02) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPA interviewed a client, and reviewed staff and client records. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in visible areas of the facility.

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

An exit interview was conducted with Administrator Diane Diaz and Licensee Aeriaka Jacobs to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

During the visit, LPA obtained a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23).

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

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