374604078-4-5-2024-08-AS-AROS-D42VGY-20240405162617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604078
Report Date: 04/05/2024
Date Signed: 04/05/2024 04:26:21 PM

Document Has Been Signed on 04/05/2024 04:26 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:	MARYAM RCFE		FACILITY NUMBER:	374604078
ADMINISTRATOR:	DOST, LEEDA		FACILITY TYPE:	740
ADDRESS:	4930 MAIDEN LANE		TELEPHONE:	(619) 825-7398
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	6	CENSUS: 6	DATE:	04/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Magida Houaoura, care giver		TIME COMPLETED:	04:45 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) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Care Giver Magida Houaoura, after identifying herself and stating the purpose of the inspection. Administrator Maria Lerma later joined the visit. According to the facility’s license, the facility serves six ambulatory elderly residents: ages 60 and above. LPA was accompanied by Administrator Maria Lerma, during a tour of the facility, which was conducted inside and out and included a sample of resident bedrooms, common area, dining area. The last disaster drill was conducted in January 2024. Exterior and interior passageways were free from obstructions. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. A fireplace with appropriate screening was observed in the main area of the building. No pools or bodies of water were observed on the premises. Resident’s room temperatures were within a comfortable range. Hot water temperature at taps accessible to residents were all compliant. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings and appropriate lighting to ensure the comfort and safety of residents. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Non-skid mats are present in the showers. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

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: MARYAM RCFE	FACILITY NUMBER: 374604078
	VISIT DATE: 04/05/2024

NARRATIVE

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[Continued on 809]

Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Medications are locked in a locked closet, not accessible to residents. Medications were labeled and kept in compliance with label instructions.

LPA interview with staff indicates the facility is providing assistance to meet necessary incidental medical and dental needs. This includes arranging or assisting in arranging transportation. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents.

LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No deficiencies were observed or cited.

An exit interview was conducted and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) was provided to the Administrator Maria Lerma, whose signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC809 (FAS) - (06/04)

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