<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604164
Report Date: 10/17/2023
Date Signed: 11/14/2023 08:02:59 AM

Document Has Been Signed on 11/14/2023 08:02 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HAILEY'S SPRING VALLEYFACILITY NUMBER:
374604164
ADMINISTRATOR:HURTADO, SAMUELFACILITY TYPE:
735
ADDRESS:8866 NOELINE AVETELEPHONE:
(619) 729-0344
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 2DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Rosa Elva Miranda, Caregiver
& Samuel Hurtado Administrator		TIME COMPLETED:
02:20 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) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Rosa Elva Miranda, Caregiver, to whom LPA discussed the purpose of the visit. Samuel Hurtado, Administrator arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) developmentally disabled adults. During today’s inspection, two (2) client was in care, and the two (2) were at day program. LPA, accompanied by the caregiver, toured the interior and exterior 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, screens, 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 client activities. The facility’s internal temperature was compliant at 70 F. Hot water temperature at taps accessible to clients were last measured at 119 degrees.



There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.


[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: HAILEY'S SPRING VALLEY
FACILITY NUMBER: 374604164
VISIT DATE: 10/17/2023
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
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Sam Hurtado, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was purchased brand new in 2022. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff present. Two clients were present and both were able to carry on a conversation. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond.

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

An exit interview was conducted with Samuel Hurtado Administrator to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2