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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603665
Report Date: 07/06/2022
Date Signed: 07/06/2022 02:37:34 PM


Document Has Been Signed on 07/06/2022 02:37 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, 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: 6DATE:
07/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Nester Blay, CaregiverTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to follow up on a Plan of Correction (POC) for deficiencies cited during a visit conducted on May 26, 2022.

The facility was cited for flooring in the dining room which was found to be in disrepair. The facility's POC was due June 9, 2022 but had also been informed that if additional time was needed to meet the POC due date, they just need to make that request. The facility did make a request for additional time and was officially granted the request during today's visit. LPA spoke with Administrator Mark Loo via telephone to clarify what repairs must be made to the flooring. LPA clarified that the gaps in the flooring must be repaired in order to help prevent an injury to a resident, staff, or visitor as a result from catching their feet, shoes, etc. in the gap and falling.
The facility is granted until August 17, 2022 to complete this repair.

No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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