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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602972
Report Date: 11/03/2021
Date Signed: 11/03/2021 05:03:05 PM

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:PLAZA VILLAGE SENIOR LIVINGFACILITY NUMBER:
374602972
ADMINISTRATOR:SHETLER, MARIAFACILITY TYPE:
740
ADDRESS:950 L AVETELEPHONE:
(619) 474-4844
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:85CENSUS: 64DATE:
11/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Manager Mike ShetlerTIME COMPLETED:
03:50 PM
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Licensing Program Manager (LPM) John Rante conducted an unannounced Case Management visit. LPM met with Manager Mike Shelter and Administrator Maria Shetler, and we discussed the purpose of the visit.

The Licensee submitted an application to the Regional Office (RO) received on September 22, 2021, to change the facility's floor plan and approve the delayed egress inside the facility. The Fire Safety Inspection Request (STD850) was completed by the local fire authority and received in the RO on October 21, 2021. The requested fire clearance has been approved by the local fire marshal, which includes the facility's new floor plan and the use of delayed egress. The facility's capacity of 85, remains the same (ambulatory: 38; non-ambulatory: 47; bedridden: 0).

LPM conducted a tour of the facility, and observed no immediate health or safety issues.

This portion of the application process has been completed. The Licensee will be sent an updated license to reflect the new fire clearance, which incudes the use of the new floor plan for residents.

An exit interview was conducted with Maria Shetler. The Licensee will be provided a copy of their appeal rights (LIC9058 01/16) via electronic mail. An electronic read receipt will serve as confirmation of documents received.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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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