374603041-1-30-2025-08-AS-CLOZ-DDF39W-20250130170350

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603041
Report Date: 01/28/2025
Date Signed: 01/30/2025 05:04:03 PM

Document Has Been Signed on 01/30/2025 05:04 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:	BANDOLA RESIDENTIAL CARE		FACILITY NUMBER:	374603041
ADMINISTRATOR/ DIRECTOR:	DOMDOM, NOVELITA V.		FACILITY TYPE:	735
ADDRESS:	4096 VIA DE LA BANDOLA		TELEPHONE:	(619) 690-1290
CITY:	SAN YSIDRO	STATE: CA	ZIP CODE:	92173
CAPACITY: 6		CENSUS: 3	DATE:	01/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:20 PM
MET WITH:	Licensee Novelita Domdom, Administrators Daisy Juanitas and Dahlia Porter		TIME VISIT/ INSPECTION COMPLETED:	05:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Administrator’s Daisy Juanitas and Dahlia Porter, and Licensee Novelita Domdom. LPA discussed the purpose of the visit with Licensee Domdom, and Administrator’s Juanitas and Porter. According to the facility’s license, there may be a maximum of six (6) clients all of whom may be non-ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is three (3) clients living at the facility. There were no clients present at the facility site during the inspection, but arrived later from their respective day program. LPA, accompanied by Licensee Domdom and Administrator Porter, 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, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 70 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: Kitchen sink measured hot water at 116.4 degrees F; sink in restroom #1 delivered hot water at 118.8 degrees F; sink in restroom #2 delivered hot water at 115.2 degrees F; sink in restroom #3 measured hot water at 116.4 degrees F; and sink in restroom #4 measured hot water at 116.2 degrees F. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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: BANDOLA RESIDENTIAL CARE	FACILITY NUMBER: 374603041
	VISIT DATE: 01/28/2025

NARRATIVE

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[CONTINUED FROM LIC 809]

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking, dining equipment and utensils were present, and all safely stored. There were no toxic chemicals or poisons accessible to clients. Medications were properly labeled, as required, and stored in locked cabinet that LPA inspected. The facility-maintained medication logs which LPA reviewed.

No pools or bodies of water on the premises. Per Administrator Juanitas, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present (02) and serviced within the last 12 months. First aid kits were complete and readily accessible.

LPA briefly spoke with clients, and reviewed staff and client records. During today’s visit there were 3 clients on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were no deficiencies observed or cited during today's annual inspection.

An exit interview was conducted with Administrator Daisy Porter and Licensee Novelita Domdom to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Administrator Porter and Licensee Domdom to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-D, to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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