374602930-11-28-2023-08-AS-ADOO-CY27WV-20231128210210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602930
Report Date: 11/28/2023
Date Signed: 11/28/2023 09:03:01 PM

Document Has Been Signed on 11/28/2023 09:03 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:	LUCIE'S SHADY REST		FACILITY NUMBER:	374602930
ADMINISTRATOR:	ZACHAY, GILBERT		FACILITY TYPE:	740
ADDRESS:	7142 BOBHIRD		TELEPHONE:	(619) 741-4460
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY:	6	CENSUS: 6	DATE:	11/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Monica Leon Caregiver		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Monica Leon Caregiver and spoke with Licensee Maria Zachay on the phone.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom must be ambulatory. During today’s inspection, there were a total of six (6) clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA Domingo, 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 74 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 110 F, Bathroom #1 sink was 110 F, and Bathroom #2 sink was 111 F.

Refrigerator temperature was 35 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 809C]

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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: LUCIE'S SHADY REST	FACILITY NUMBER: 374602930
	VISIT DATE: 11/28/2023

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[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 clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files 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 Caregiver Monica Leon to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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