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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603665
Report Date: 07/30/2023
Date Signed: 07/30/2023 10:07:59 AM


Document Has Been Signed on 07/30/2023 10:07 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 5DATE:
07/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:57 AM
MET WITH:LEAD CAREGIVER, NESTOR BLAYTIME COMPLETED:
10:12 AM
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On July 30, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection. LPA Mixson met with Lead Caregiver, Nestor, introduced herself, and stated the purpose of the visit.

LPA Mixson toured the facility and inspected the inside and outside of the facility. The facility is a single story home located at 1814 Devon Place, Vista, Ca. 92084. LPA Mixson interviewed the Administrator, Mark Loo via the telephone. Physical Plant: The physical plant is clean, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of the inspection. The facility has six bedrooms, and each bedroom has the required furniture and storage space, and sufficient lighting. The bedrooms were equipped with the required items as per Title 22 regulations. The hot water temperature was tested and within regulations. The three restrooms were equipped with liquid soap and paper towels. The LPA toured the kitchen, living room and the TV room. The kitchen area was clean, organized, and free or odors. LPA Mixson observed the menu posted. One caregiver was present preparing the morning meal, and one caregiver was attending to the residents. The food requirements were met, the seven day supply of non perishables, and the two day supply of perishable. The LPA inspected the common areas, and the laundry room. Smoke detectors were in the green and operable. The fire extinguisher was in the green, and last reviewed for services in 2023. Carbon monoxide detectors, along with smoke detectors were observed, and were operable. There was a locked and centralized storage cabinet area for medications. Medications are contained in bubble packs and are delivered by a pharmacy. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space.
The LPA observed the previous Community Care Licensing (CCL), forms which are required to be available at the facility for public review for three years.
LPA Mixson reviewed four staff files, five resident files, and conducted one staff interview and interviewed the Administrator via the telephone, and no resident were interviewed at this time due to meals and ADLs.

There were no observable Title 22, Division 6 Regulation violations observed and/or cited during todays visit.

An exit interview was conducted and a copy of this report was provided to the Lead Caregiver Nestor Blay.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2023
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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