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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602750
Report Date: 10/15/2024
Date Signed: 11/05/2024 07:55:20 AM

Document Has Been Signed on 11/05/2024 07:55 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ELMIRA HOME CAREFACILITY NUMBER:
374602750
ADMINISTRATOR/
DIRECTOR:
JENKINS, VALERIEFACILITY TYPE:
735
ADDRESS:361 ELMIRA STREETTELEPHONE:
(619) 749-9761
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 4CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Direct Support Professional Manuel MarquezTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Direct Support Professional Manuel Marquez. Assistant Administrator Christiana De Leon arrive shortly after. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom must all be ambulatory.

LPA Strong, 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. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Two days of perishable food and seven days of non-perishable food was present. Medications was observed to be locked.

No pools or bodies of water on the premises. Per Manuel no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Water temperature was measured at 108 degrees F.

Confidential records were stored in locked areas. Client record reviewed contained required documents. Staff records reviewed contained required documents.

No deficiencies were observed or cited during today's annual inspection.
An exit interview was conducted with Assistant Administrator Christiana De Leon, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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