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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602750
Report Date: 03/02/2023
Date Signed: 03/02/2023 02:11:45 PM

Document Has Been Signed on 03/02/2023 02:11 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ELMIRA HOME CAREFACILITY NUMBER:
374602750
ADMINISTRATOR:JENKINS, VALERIEFACILITY TYPE:
735
ADDRESS:361 ELMIRA STREETTELEPHONE:
(619) 749-9761
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 4CENSUS: 4DATE:
03/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Valerie Jenkins, LicenseeTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit and concurrently conducted a case management visit to the facility and provided Technical Advisory’s (TA). LPA Lopez identified herself and was granted entry by Valerie Jenkins, Licensee. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Licensee Jenkins. House Manager Christiana Jenkins DeLeon later arrived and joined the visit.

During the visit, LPA toured the facility, requested and obtained records. During the tour, LPA observed ceiling fan needed to be cleaned in the kitchen area. LPA reviewed Title 22, Division 6, Chapter 1, Article 07, Section 80087 Buildings and Grounds, with Licensee Jenkins, and House Manager DeLeon. Additionally, during the file reviews of client records LPA observed records were incorrect for four out of four clients in care. LPA reviewed Title 22, Division 6, Chapter 1, Article 6, Section 80070 Client Records, with Licensee Jenkins and House Manager DeLeon. Technical Advisory notices were given during today’s visit.

An exit interview was conducted with Administrator Jenkins and House Manager DeLeon. A copy of this report, and Applicant/Licensee Rights (LIC 9058 03/22) were provided to Licensee at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
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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