374603863-3-12-2024-08-AS-CLOZ-D3AT4Z-20240312142445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603863
Report Date: 03/12/2024
Date Signed: 03/12/2024 02:25:23 PM

Document Has Been Signed on 03/12/2024 02:25 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:	VILLA SAN JAVIER		FACILITY NUMBER:	374603863
ADMINISTRATOR:	ENRIQUEZ,RICHARD		FACILITY TYPE:	735
ADDRESS:	725 CAMELOT PARKWAY		TELEPHONE:	(619) 948-9177
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY: 4		CENSUS: 4	DATE:	03/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Elizabeth Enriquez, Administrator		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Direct Support Professional (DSP) Erika Hernandez Marron. LPA discussed the purpose of the visit with DSP Marron. Administrator Elizabeth Enriquez later arrived and joined the visit. According to the facility’s license, there may be a maximum of four (4) clients all of whom may be non-ambulatory, with delayed egress, in at any given time at the facility site. During today’s inspection, the facility’s current census is 4 clients living at the facility. There were 4 clients present at the facility site during the inspection. LPA, accompanied by DSP Hernandez and Administrator Enriquez, toured the interior and exterior sections 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, 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 activities. The facility’s ambient internal temperature was comfortable and compliant, at 68 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink delivered hot water at 115.3 degrees F; sink in restroom #1 delivered hot water at 117.7 degrees F; sink in restroom #2 delivered hot water at 115.5 degrees F; laundry room delivered hot water at 118.8 degrees F. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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: VILLA SAN JAVIER	FACILITY NUMBER: 374603863
	VISIT DATE: 03/12/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to clients. LPA inspected medications and found that they were properly labeled, as required, and stored in locked area. The facility maintained medication logs which LPA reviewed.

No pools or bodies of water on the premises. Per Administrator Enriquez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present (02) and serviced within the last 12 months. First aid kit(s) were complete and readily accessible.

LPA was able to interview staff and client, and reviewed staff and client records. During today’s visit there were 4 clients on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

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

An exit interview was conducted with Administrator Elizabeth Enriquez to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Administrator Enriquez to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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