374602591-11-14-2023-08-AS-THOS-CXKSER-20231114124911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602591
Report Date: 11/14/2023
Date Signed: 11/14/2023 04:05:56 PM

Document Has Been Signed on 11/14/2023 04:05 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:	CASA PRIMAVERA		FACILITY NUMBER:	374602591
ADMINISTRATOR:	LUZ MARIA CHAVEZ		FACILITY TYPE:	740
ADDRESS:	848 FELICITA AVE		TELEPHONE:	(619) 589-7112
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY:	6	CENSUS: 5	DATE:	11/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:12 AM
MET WITH:	Sandra Sandavol, Caregiver & Rudy Chavez, Administrator		TIME COMPLETED:	12:55 PM

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Licensing Program Analyst (LPA) Tiffany Holmes 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 Sandra Sandoval, Caregiver to whom LPA discussed the purpose of the visit. Rudy Chavez, Administrator arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) elderly adults, all ambulatory. During today’s inspection, LPA observed five (5) residents were at home and resting.

LPA, accompanied by the Administrator, 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 76 F. Hot water temperature last measured at 108 degrees.

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]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

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: CASA PRIMAVERA	FACILITY NUMBER: 374602591
	VISIT DATE: 11/14/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Chavez, 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 kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff present and residents at the facility during the visit. LPA reviewed multiple staff andresident records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond.

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

An exit interview was conducted with Rudy Chavez, Administrator to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

LIC809 (FAS) - (06/04)

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