<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602639
Report Date: 03/23/2023
Date Signed: 03/23/2023 11:40:44 AM

Document Has Been Signed on 03/23/2023 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PRINCESS BOARD & CARE CORP.FACILITY NUMBER:
374602639
ADMINISTRATOR:GUMABON, REMEDOR C.FACILITY TYPE:
735
ADDRESS:1203 EAST 1ST STREETTELEPHONE:
(619) 434-7343
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 4CENSUS: 4DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Remedor "JR" Gumabon, Jr. and Staff Remel GumabonTIME COMPLETED:
11:45 AM
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 Analysts (LPAs) Dang Nguyen and Alyssa Ramirez 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 Administrator Remedor "JR" Gumabon, Jr. and Staff Remel Gumabon.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, all of whom must be ambulatory. During today’s inspection, there were a total of four (4) clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPAs, accompanied by licensee’s staff, 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 and 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 71 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 114 F, Bathroom #1 sink was 115 F, and Bathroom #2’s sinks were 114 F and 115 F, respectively.

Refrigerator temperature was 40 F and freezer temperature was 0 F. 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, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PRINCESS BOARD & CARE CORP.
FACILITY NUMBER: 374602639
VISIT DATE: 03/23/2023
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
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809]

No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPAs interviewed multiple staff and reviewed multiple staff and client records/files. During today’s visit, all clients were off-site at a day program and thus were not interviewed. LPA’s interviews did not raise any licensing concerns. The files which LPAs reviewed contained required documents. Confidential records were stored in locked areas. Licensee's staff also 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 the Gumabons, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2