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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604149
Report Date: 06/07/2024
Date Signed: 06/07/2024 05:06:12 PM


Document Has Been Signed on 06/07/2024 05:06 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:NORTH COUNTY CARE HOMEFACILITY NUMBER:
374604149
ADMINISTRATOR:CAMPAS, CARMENFACILITY TYPE:
740
ADDRESS:15042 AMSO STTELEPHONE:
(858) 842-4608
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 4DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Caregiver Jethro Mendoza and Administrator Tess DereferaTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Jethro Mendoza. Administrator Tess Derefera joined LPA shortly thereafter.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom six (6) may be non-ambulatory of which one (1) may be bedridden. During today’s inspection, there were a total of four (4) residents in care. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by Tess Derefera, toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. 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 client activities.

Hot water temperature at taps accessible to clients were compliant.

There was at least 2 days supply of perishable food, and at least 7 days non-perishable food were present. Cooking/dining equipment and utensils were present. There were no sharp objects, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas.



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


(CONTINUED ON LIC809-C)
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana BarfieldTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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: NORTH COUNTY CARE HOME
FACILITY NUMBER: 374604149
VISIT DATE: 06/07/2024
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Confidential records were stored in locked areas. Tess Derafera also presented proof of current/active business liability insurance.

No deficiencies were observed or cited during today's annual inspection. LPA issued one (1) technical violation today.


An exit interview was conducted with Tess Derafera, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana BarfieldTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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