374604230-8-28-2026-18-AS-KWEN-DXDSUE-20260828141102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604230
Report Date: 08/28/2026
Date Signed: 08/28/2026 02:11:19 PM

Document Has Been Signed on 08/28/2026 02:11 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	KELLY'S EASTBURY VILLA		FACILITY NUMBER:	374604230
ADMINISTRATOR/ DIRECTOR:	MARYLINE SIADTO		FACILITY TYPE:	740
ADDRESS:	739 EASTBURY VILLA		TELEPHONE:	(442) 999-5170
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY: 6		CENSUS: 6	DATE:	08/28/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:20 PM
MET WITH:	Garrett Welkerelsey Simmons, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:10 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	On 8/28/26, Licensing Program Analyst (LPA) Kyle Wellington arrived unannounced to conduct an annual inspection. LPA was greeted and granted entry by Caregiver, Martha "Cece" Martinez, who was informed of the purpose of the visit. LPA met with Administrator (Admin) Garrett Welker, who also was informed of the purpose of the visit. The census at the facility is 6 residents. LPA received a resident and staff roster from Admin. LPA toured the inside and outside of the facility with Admin. LPA conducted an observation and record review for the inspection. Facility Overview: Facility is a one story house with six (6) resident bedrooms, one (1) resident bathroom, kitchen, dining room, family room, staff room, staff bathroom and attached garage. There are no pools, bodies of water or firearms at the facility. Facility has a fire clearance for six (6) non-ambulatory elderly adults of whom three (3) can be bedridden in rooms 2, 3, and 4. Hospice waiver was approved for six (6) residents. Infection Control: LPA observed hand sanitizers and soap dispensers throughout the facility. Cleaning equipment and supplies were kept in the locked garage and available for regular facility maintenance. LPA reviewed the facility’s infection control plan which met the department’s requirements. Physical Plant: LPA observed the inside and outside of the facility to be clean, safe and well kept. The family room and dining room furniture was in good repair. The residents' bedrooms and bathrooms were well maintained. The residents’ bedrooms contained the required bedding, lighting and furniture. Bathrooms had soap, paper towels, grab bars and non-slip floor in the shower. Extra linen was kept in resident's bedrooms and extra towels were kept in the resident's bathroom. Laundry equipment appeared to be in good working condition. Laundry supplies were kept in the locked garage. Two (2) fire extinguishers were charged and bought on 6/5/26. Facility has smoke and carbon monoxide detectors and a pull system fire alarm. The

Jacob Garber
Kyle Wellington
	DATE: 08/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S EASTBURY VILLA	FACILITY NUMBER: 374604230
	VISIT DATE: 08/28/2026

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front yard and backyard was free of hazards and contained outdoor furniture and shaded area for residents.

Kitchen/Food Service: LPA observed the kitchen to be clean, organized, and well maintained. The kitchen had the ability to prepare and store food in a safe and clean environment. Kitchen appliances appeared to be in good working condition. All sharp objects and cleaning supplies were kept in a locked cabinet under the kitchen sink inaccessible to residents. Facility has over a two day supply of perishable foods and over a seven day supply of non-perishable foods.

Care and Supervision: LPA observed two (2) staff and five (5) residents at the facility. One (1) resident was away from the facility at the time of the visit. Facility has sufficient staff to supervise the residents.

Administration: LPA observed facility sketch, facility license and administrator certificates posted near the front door. Long-term care ombudsman information and resident's bill of rights were also posted. Admin holds a current Administrator Certificate, CPR/First Aid Certificate and a Criminal Record Clearance.

Resident & Staff Records: LPA reviewed the records of three (3) resident files and two (2) staff files. Staff present have CPR/First Aid Certificate, criminal record clearance and are associated with the facility. The files contained all the required documentation and paperwork. The staff and resident files were kept in a locked cabinet in the kitchen inaccessible to unauthorized individuals.

Health Related Services/Incidental Medical Services: LPA observed clients' medications were centrally stored in locked storage carts in the kitchen inaccessible to residents. First aid kit was kept in locked storage carts in the kitchen and it contained all the required items. LPA reviewed three (3) residents' medications to the facility’s medication log to make sure all medication was accounted for and dispensed correctly.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan. It is current and up to date. Fire drills are done quarterly and was last completed on 8/5/26. Facility's property and liability insurance is current and expires on 8/16/27. All facility exits were clear of obstructions.

No deficiencies were cited during this visit. An exit interview was conducted with the Administrator, Garrett Welker, and a copy of this report was given to Administrator, Garrett Welker.

NAME OF LICENSING PROGRAM MANAGER: Jacob Garber
NAME OF LICENSING PROGRAM ANALYST: Kyle Wellington
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026

LIC809 (FAS) - (06/04)

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