<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603587
Report Date: 02/08/2024
Date Signed: 02/08/2024 06:50:37 PM

Document Has Been Signed on 02/08/2024 06:50 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:CHANCELLOR HOMEFACILITY NUMBER:
374603587
ADMINISTRATOR:ASTRID GARCIAFACILITY TYPE:
735
ADDRESS:13904 CHANCELLOR WAYTELEPHONE:
(858) 842-4534
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 4CENSUS: 3DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Direct Support Professional (DSP) Karla LopezTIME COMPLETED:
01:15 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) Debbie Correia conducted an unannounced Required Annual Inspection. LPA identified herself and was welcomed by Direct Support Professional (DSP) Karla Lopez to whom was explained the purpose of the visit. Home Supervisor (HS) Elizabeth Thompson and Licensee Astrid Garcia later arrived to meet with LPA. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which all may be non-ambulatory. There was a total of three (3) clients in care.

LPA, accompanied by DSP Lopez and HS Thompson, 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, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature at taps accessible to clients were all compliant: Bathrooms used by client's hot water measured at 112 F and 113.4 F, and the facility temperature was 77 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored and labeled. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications and toxins l and stored in locked areas inaccessible to clients in care.




[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CHANCELLOR HOME
FACILITY NUMBER: 374603587
VISIT DATE: 02/08/2024
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
26
27
28
29
30
31
32
No pools or bodies of water were present. Per HS Thompson there was no ammunition kept at the facility. Smoke alarms, carbon monoxide detectors, and facility telephone were all operable. Fire extinguisher(s) were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. All required records for clients and staff were present and current.

No deficiencies were cited during today's annual inspection.

An exit interview was conducted with HS Thompson and Licensee Garcia to whom a copy of this report and Licensee/Appeal Rights (LIC9058 03/22) will be provided. Signature below confirms receipt of the reports.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2