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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603669
Report Date: 10/24/2023
Date Signed: 10/25/2023 07:05:21 AM

Document Has Been Signed on 10/25/2023 07:05 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HABILITATIVE HOMES RESIDENTIAL CARE FACILITYFACILITY NUMBER:
374603669
ADMINISTRATOR:DAVID LARSONFACILITY TYPE:
735
ADDRESS:11775 WALNUT ROADTELEPHONE:
(619) 270-4484
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 6DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Licensee David LarsonTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct the required annual licensing inspection. LPA was granted entry into the facility by Licensee Larson, identified herself, and stated the purpose of today’s visit, to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

During today's visit there were 6 clients and 2 staff present. LPA Correia conducted a general overall inspection. The facility's temperature was 79 degrees Fahrenheit at the time of the visit. The client bathroom's hot water temperature measured 115 degrees Fahrenheit. Disinfectants, cleaning solutions, poisons were inaccessible to clients. All client rooms were equipped with the required furnishings. Client bathrooms were observed to be sanitary and equipped with the required supplies. Grab bars and non-skid flooring were present for showers and bathtub used by clients. Lighting was maintained in hallways and passages to client bathrooms. Facility stairwell was equipped with an evacu-chair. Facility has no bodies of water on the premises. The Licensee provided each client with clean linen in good repair, and sufficient hygiene products for personal use. LPA Correia observed smoke alarms, and carbon monoxide detectors throughout the facility that were in operable condition. Per Licensee there are no weapons and/or ammunition housed in the facility.

The facility is stocked with a 2 day supply of perishable and 7 day supply of nonperishable food items. The food was observed properly stored. Medications are stored in a locked cabinet and administered according to the label instructions. The facility's last disaster drill was conducted on 10/6/2023.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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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: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
VISIT DATE: 10/24/2023
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Per staff records reviewed, individuals subject to a criminal record review obtained clearance and/or an exemption; staff responsible for direct care and supervision have current First Aid and CPR training. Administrator Certificate expires 10/15/2024.

Based on today's visit, there were no deficiencies observed at this time in the areas evaluated. An exit interview was conducted with Licensee Larson and will be provided a copy of this report and licensee/appeal rights (LIC 9058 01/16) and signature on this form acknowledges receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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