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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604219
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:36:24 PM

Document Has Been Signed on 06/14/2023 02:36 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REAL HOMEFACILITY NUMBER:
374604219
ADMINISTRATOR:QUITEVIS, JHODEEFACILITY TYPE:
734
ADDRESS:2281 RITTER PLACETELEPHONE:
(650) 238-4987
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 5CENSUS: 4DATE:
06/14/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:NURSE, MARVYNE BAN-EGTIME COMPLETED:
02:43 PM
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On 06/14/2023, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management health and safety visit. LPA Mixson met with the Facility Nurse and explained the purpose of the visit.

LPA Mixson toured the facility and observed three residents currently in the facility, and one resident was in the hospital. Additionally, there were two nurses, two caregivers, and a Respiratory Therapist. There are no imminent health and/or safety concerns observed at the time of visit. LPA Mixson observed no health and/or safety hazards inside the facility. LPA observed facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA Mixson assessed the available food supply and observed that the supply exceeds the requirement of a two days supply of perishable foods and a seven days supply of non-perishable foods. Medications were found to be in sufficient supply as well. LPA Mixson interviewed the Facility Nurse, requested and received pertinent documentation. The Facility Nurse stated that the Resident passed away while on Palliative Care and in the hospital. The Resident left the facility on 04/20/20223 by 911. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to the Facility Nurse.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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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