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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604204
Report Date: 11/21/2023
Date Signed: 12/01/2023 11:03:06 AM


Document Has Been Signed on 12/01/2023 11:03 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:LA VALHALLA RESIDENTIAL CAREFACILITY NUMBER:
374604204
ADMINISTRATOR:DE VERA, JONATHANFACILITY TYPE:
740
ADDRESS:1701 LA VALHALLA PLTELEPHONE:
(619) 499-5853
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:6CENSUS: 2DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Caregiver Ferdinand De VeraTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Iby Strong 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 Caregiver Ferdinand De Vera and Caregiver Ofelia DeVera. According to the facility’s license, the facility has a maximum capacity of six (6) residents, all of whom may be non-ambulatory and one may be bedridden.

LPA 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, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

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 toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas.



No pools or bodies of water on the premises. Per Caregiver, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

Confidential records were stored in locked areas.

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

An exit interview was conducted with Caregiver Ferdinand De Vera, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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