374603596-1-26-2024-08-AS-LSIA-CZUSG9-20240126125134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603596
Report Date: 01/26/2024
Date Signed: 01/26/2024 12:52:12 PM

Document Has Been Signed on 01/26/2024 12:52 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:	PEOPLE'S CARE JOHNSON LAKE		FACILITY NUMBER:	374603596
ADMINISTRATOR:	SILVIA DAVALOS		FACILITY TYPE:	735
ADDRESS:	11691 JOHNSON LAKE DR		TELEPHONE:	(619) 390-1380
CITY:	LAKESIDE	STATE: CA	ZIP CODE:	92040
CAPACITY: 4		CENSUS: 4	DATE:	01/26/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Silvia Davalos		TIME COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to continue a required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with caregiver Maria Davalos. Administrator Silvia Davalos arrived shortly after.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, two of whom may be non-ambulatory. During today’s inspection, there were a total of four (4) clients in care, and per medical records, all were ambulatory. This facility features a secured perimeter.

LPAs, accompanied by the Administrator, 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 119.3 F, Bathroom #1 sink was 119.7 F, Bathroom #2 sink was 120 F and Bathroom #3 was 105.9 F.

Refrigerator temperature was 40 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.

No pools or bodies of water were observed on the premises. Per Administrator Silvia Davalos, no firearms or ammunition are kept at the facility.[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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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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: PEOPLE'S CARE JOHNSON LAKE	FACILITY NUMBER: 374603596
	VISIT DATE: 01/26/2024

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[CONTINUED FROM LIC 809] 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.

LPA interviewed staff and clients. LPA reviewed 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. The Administrator also presented proof of current business liability insurance and surety bond.

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

An exit interview was conducted with Silvia, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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