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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602717
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:47:57 PM

Document Has Been Signed on 12/19/2023 02:47 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:M & M RESIDENTIALFACILITY NUMBER:
374602717
ADMINISTRATOR:JENKINS, MAKAILA AFACILITY TYPE:
735
ADDRESS:1504 WHITESTONE ROADTELEPHONE:
(619) 825-8487
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 4DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Makaila Jenkins, AdministratorTIME COMPLETED:
10:55 AM
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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 Makaila Jenkins, Administrator to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) developmentally disabled adults, all ambulatory. During today’s inspection, four (4)clients were at day program.

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 comfortable.

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]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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: M & M RESIDENTIAL
FACILITY NUMBER: 374602717
VISIT DATE: 12/19/2023
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Jenkins, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher has been serviced. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff present. There were no clients at the facility during the visit. LPA reviewed multiple staff and client 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 Administrator Jenkins to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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