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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603736
Report Date: 08/19/2022
Date Signed: 08/19/2022 02:15:59 PM


Document Has Been Signed on 08/19/2022 02:15 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:GARCIA-ENDOZO SENIOR HOME LLCFACILITY NUMBER:
374603736
ADMINISTRATOR:ENDOZO, ARLENE GARCIAFACILITY TYPE:
740
ADDRESS:850 HALECREST DRIVETELEPHONE:
(619) 576-3735
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: 3DATE:
08/19/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Arlene Garcia Endozo, AdministratorTIME COMPLETED:
01:38 PM
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Licensing Program Analyst (LPA) Esther Miller conducted an announced case management visit due to a request to change the facility floor plan. LPA identified herself and met with Arlene Garcia Endozo, Administrator, and discussed the purpose of the visit. Community Care Licensing last visited the facility for a Healthcare-Associated Infections (HAI) Program visit on June 22, 2022, during which time no deficiencies were cited.

The Licensee submitted an application to the Regional Office (RO) to change the facility's floor plan on March 1, 2022. The Fire Safety Inspection Request (STD850) was completed by the Chula Vista Fire Department on July 26, 2022. STD850 stated "Age range 60 and over; six (6) non-ambulatory, of which one (1) may be bedridden. Bedridden resident will be moved to room #6. Room #5 will be a staff bedroom."

LPA conducted a tour of the facility and observed no immediate health or safety issues. Previously, room #4 had fire clearance for bedridden, but fire clearance received on July 26, 2022 indicated that only room #6 will be bedridden. Administrator will contact Chula Vista Fire Department to reinstate room #4 to have bedridden clearance.

This portion of the application process has been completed. The Licensee will be sent an updated license to reflect the new fire clearance, which includes the use of the new floor plan for residents.

An exit interview was conducted with Administrator. The Administrator was provided a copy of this report and their appeal rights (LIC9058 01/16).
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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