374602563-10-24-2025-08-AS-JDLC-DMRTWR-20251024150559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602563
Report Date: 10/16/2025
Date Signed: 10/24/2025 03:06:24 PM

Document Has Been Signed on 10/24/2025 03:06 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:	DIANA DIAZ		FACILITY TYPE:	735
ADDRESS:	5899 TOOLEY STREET		TELEPHONE:	(619) 266-0752
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY: 4		CENSUS: 3	DATE:	10/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Administrator Diana Diaz		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with caregiver S1, and were later joined by Administrator Diana Diaz.

LPA arrived at the facility at 8 am. According to the facility’s administrator, the facility has a maximum capacity for four (4) clients, one of which can be non-ambulatory. The facility currently has three (3) residents in care, all of whom are ambulatory. From 8 am to 8:30 am, LPA observed clients in care having breakfast while staff helped them, after which they left the facility. At 8:30 am, LPA counted clients funds and reviewed clients files, from which LPA learned that facility has 1 client with type 1 and two (2) clients with type 2 diabetes. At 9:50 am, LPA reviewed staff files.

At 11:16 am, LPA toured the facility along with Administrator starting with the kitchen. Sharps and chemicals where stored and locked, food was enough for 2 days for fresh food and 7 days for stored food, tab water temperature was 111.3 F at the sink. At 11:22 am they toured a resident room, which was compliant with furniture, fire alarm, sheet protector, window screen. Clients room have personal items, clothes and is clean. At 11:24, LPA and Administrator entered Bathroom #1, which was compliant, water temperature in the sink was of 115 F. At 11:32 am, LPA and Administrator entered C3’s room, which was compliant with laws and regulations. At 11:35 am LPA and Administrator entered the second bathroom, which was compliant, and water temperature in the sink reached 108 F.

[CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Jose DeLaCruz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 10/16/2025

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[CONTINUED FROM LIC809]

At 11:40, LPA and administrator entered the locked garage, where washing machine and dryer were observed, as well as PPE. No Chemicals or poisons where observed. At 12:00 pm LPA and Administrator went to the back yard. Shaded area with furniture for residents to sit, no chemicals or poisons, water valve shuts were shown, no pools or other hazards found. Trash bins are complete and in good condition.

At 12:22 pm, LPA interviewed S1, after which left the facility for lunch.

At 2:00 pm, LPA interviewed C2, at 2:15 pm interviewed C1, and at 2:30 pm C3.

No deficiencies were cited during today’s annual inspection. An exit interview was conducted with Administrator Diana Diaz, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Jose DeLaCruz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

LIC809 (FAS) - (06/04)

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