374602673-4-4-2024-08-AS-CLOZ-D4243F-20240404184441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602673
Report Date: 04/04/2024
Date Signed: 04/04/2024 06:45:43 PM

Document Has Been Signed on 04/04/2024 06:45 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 ESTRELLA 11TH ST		FACILITY NUMBER:	374602673
ADMINISTRATOR/ DIRECTOR:	MICHELLE MUNOZ		FACILITY TYPE:	735
ADDRESS:	1125 11TH STREET		TELEPHONE:	(619) 651-1177
CITY:	IMPERIAL BEACH	STATE: CA	ZIP CODE:	91932
CAPACITY: 6		CENSUS: 6	DATE:	04/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:15 PM
MET WITH:	Michelle Munoz, Licensee		TIME VISIT/ INSPECTION COMPLETED:	06:50 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 Direct Support Professional (DSP) Norma Ramirez Terrones. LPA discussed the purpose of the visit with DSP Terrones. Licensee Michelle Munoz later arrived and joined the visit. According to the facility’s license, there may be a maximum of six (6) clients all of whom must be ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 6 clients living at the facility. There was 6 clients present at the facility site during the inspection. LPA, accompanied by Licensee Munoz, 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 68 F. Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured hot water at 114.8 degrees Fahrenheit (F); sink in restroom #1 delivered hot water at 107.8 degrees F; and sink in restroom #2 delivered hot water at 108 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were properly labeled, as required, and stored in locked cabinet. 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: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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: CASA ESTRELLA 11TH ST	FACILITY NUMBER: 374602673
	VISIT DATE: 04/04/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per licensee Munoz, 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 (02) and serviced within the last 12 months. First aid kit(s) were complete and readily accessible.

LPA interviewed staff and clients, and reviewed staff and client records. During today’s visit there were 6 clients on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked cabinet. Required licensing postings were observed in a visible area of the facility.

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

An exit interview was conducted with Licensee Michelle Munoz 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.

Licensee provided LPA a copy of the 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), during the inspection.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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