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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604243
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:23:11 PM

Document Has Been Signed on 10/10/2023 03:23 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PLUMOSA PLFACILITY NUMBER:
374604243
ADMINISTRATOR:ORR, DIANFACILITY TYPE:
735
ADDRESS:181 PLUMOSA PLTELEPHONE:
(760) 505-5409
CITY:OCEANSIDESTATE: CAZIP CODE:
92058
CAPACITY: 4CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Drew OrrTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Administrator Drew Orr.

According to the facility's license, the facility has a maximum capacity of 4 clients, 1 of which may be non-ambulatory. During today's inspection, there were 4 clients in care and all were ambulatory.

During today's visit, LPA toured the facility and inspected client rooms, bathrooms, kitchen, garage, living room, and outside area. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility's water temperature was measured at 108.5 degrees Fahrenheit in a client bathroom. LPA observed all hazardous and/or toxic chemicals were stored and secured and stored separately from food supplies. LPA observed locked storage for clients' medications and files. A functioning carbon monoxide detector and smoke detectors were observed in the facility. No bodies of water were observed on the premises. LPA observed 7-day supply of non-perishable food and a 2-day supply of perishable food. According to the Administrator, there are no firearms or weapons stored at the facility. The facility’s ambient internal temperature was measured at 74 degrees Fahrenheit. The kitchen and garage refrigerator temperatures were both measured at 40 degrees Fahrenheit. The kitchen and garage freezer temperatures were both measured at 0 degrees Fahrenheit. LPA observed cooking and dining utensils were present and kitchen appliances were in working order.


Continued on LIC809-C page...
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PLUMOSA PL
FACILITY NUMBER: 374604243
VISIT DATE: 10/10/2023
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During the visit, LPA reviewed multiple client and staff files and interviewed multiple staff and one client who was present at the facility during the inspection. Review of the client and staff files did not reveal any missing or incomplete documents. Review of client medications did not reveal any inconsistencies. All staff present at the facility were fingerprint cleared and associated with the facility. Interviews with staff and clients did not reveal any licensing or regulatory concerns.

No deficiencies were observed or cited on today's date. An exit interview was conducted with Direct Support Provider Hervea Byrton Slack, whose signature below confirms receipt of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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