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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604230
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:28:13 PM


Document Has Been Signed on 08/30/2023 03:28 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:KELLY'S EASTBURY VILLAFACILITY NUMBER:
374604230
ADMINISTRATOR:MARYLINE SIADTOFACILITY TYPE:
740
ADDRESS:739 EASTBURY VILLATELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:FACILITY MANAGER, KELSEY SIMMONSTIME COMPLETED:
03:45 PM
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On August 30, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection. LPA Mixson met with the Facility Manager Kelsey Simmons, introduced self, and stated the purpose of the visit.

LPA Mixson toured the facility and inspected the inside and outside of the facility. The facility is a single story building located at 739 EastBury Drive, Escondido, Ca. 92027.
Physical Plant: The physical plant is clean, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of the inspection. The facility has seven bedrooms, and each room has the required furniture and storage space, and sufficient lighting. All rooms were equipped with the required items as per Title 22 regulations. The hot water temperature was tested and was within regulations. The restrooms were equipped with liquid soap and paper towels. The LPA toured the kitchen, living room and the TV room. The kitchen area was clean, organized, and free or odors. The facility grocery shops for food weekly and as needed. All food requirements were met, the seven day supply of non perishables, and two day supply of perishable. The LPA inspected the common areas, and the laundry area in the garage. Smoke detectors were in the green and operable. The fire extinguisher was in the green, and last reviewed for services on 08/07/2023. Carbon monoxide alarms, along with smoke detectors were observed. There was a locked and centralized storage area for medications. Medications are contained in bubble packs and are delivered by the pharmacy. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space for family visitors. LPA Mixson observed the SEE Something Say something posted in visible areas. LPA Mixson reviewed three staff files, five resident files, and conducted two staff interviews and three resident interviews. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit. An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to the Facility Manger, Kelsey Simmons.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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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