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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604204
Report Date: 04/15/2021
Date Signed: 04/15/2021 03:33:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:LA VALHALLA RESIDENTIAL CAREFACILITY NUMBER:
374604204
ADMINISTRATOR:DE VERA, JONATHANFACILITY TYPE:
740
ADDRESS:1701 LA VALHALLA PLTELEPHONE:
(619) 334-4588
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:6CENSUS: 3DATE:
04/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Joanathan De VeraTIME COMPLETED:
04:35 PM
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 Licensing Program Analyst (LPA) Kennedy conducted a Change in Ambulatory Status Visit via video calling app due to COVID 19 restrictions to observe the physical plant for compliance per Title 22, Division 6 of the CA Code of Regulations and Health & Safety codes. The facility has requested a change from 4 non-ambulatory and 2 ambulatory to 6 all non-ambulatory. One resident may be bedridden. A fire clearance was granted by the local fire authority and received by CCL on 4-12-21, The LPA met with licensee and administrator Jonathan DeVera. Mr. De Vera provided the LPA with a virtual tour of the facility. LPA observed resident accommodations including furnishings, linens and personal hygiene items; resident bathroom was equipped with grab bars and bath mats; food service including dishes, utensils, food storage and a seven day supply of nonperishables and a two day supply of fresh perishables are present; medication storage is located in a locked closet; first aid kit and current first aid manual are located in the main living area of the home; activities, supplies and sufficient space to conduct are present; a fire extinguisher is present and is affixed with a current tag; smoke and carbon monoxide detectors are present and operable; facility posting requirements are present in a common area and the facility administrators certification is current; no pool or other body of water is on the property; LPA observed COVID screening station and COVID postings. The LPA is recommending the change in ambulatory status.
An exit interview was conducted with Mr. De Vera via video-call. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided via email. An electronic response confirms the documents were received.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna KennedyTELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
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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