374604178-8-15-2023-08-AS-RGAZ-CUQRG4-20230815130007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604178
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:00:12 PM

Document Has Been Signed on 08/15/2023 01:00 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:	CASA DE MAYA		FACILITY NUMBER:	374604178
ADMINISTRATOR:	GONZALEZ, JOSE A.		FACILITY TYPE:	735
ADDRESS:	9643 BOTE CT		TELEPHONE:	(619) 201-0676
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY: 4		CENSUS: 4	DATE:	08/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator Jose Gonzalez Jr.		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Riza Alvarez 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 Direct Support Professional Jose Gonzalez, with whom LPA discussed the purpose of the visit. Administrator Jose Gonzalez Jr arrived shortly.

According to the facility’s license, the facility has a maximum capacity of four (4) ambulatory clients. During today’s inspection, there was a total of two (2) clients in care. One (1) client was at day program. One (1) client was in a skilled nursing facility since June 2023.

LPA, accompanied by Administrator Gonzalez, 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 ambient internal temperature was compliant at 84 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 111.6 F, bathroom #1 sink was 105.3 F and bathroom #2 sink was 106 F.

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: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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: CASA DE MAYA	FACILITY NUMBER: 374604178
	VISIT DATE: 08/15/2023

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[CONTINUED FROM LIC 809]

There was a swimming pools on the premises, which is compliant with Regulations. 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 was serviced within the last 12 months. First aid kits (2) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients present. 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 Administrator Jose Gonzalez Jr. to whom copies of this report and the Applicant/Licensee Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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