<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604253
Report Date: 11/20/2023
Date Signed: 11/20/2023 10:21:17 PM

Document Has Been Signed on 11/20/2023 10:21 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:TIZON'S PRIME CARE INC., #2FACILITY NUMBER:
374604253
ADMINISTRATOR:TIZON, GRACE CFACILITY TYPE:
735
ADDRESS:2215 SPRING OAK WAYTELEPHONE:
(619) 227-2010
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 4CENSUS: 4DATE:
11/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Grace Cosico, LicenseeTIME COMPLETED:
01:15 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
Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced Required Annual Inspection. LPA introduced herself and was granted entry into the facility by Corazon Luzano, Caregiver. The licensee, Grace Cosico, arrived a short time later, to whom LPA disclosed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, one of whom may be ambulatory. During today’s inspection, there were a total of four (4) clients in care.

LPA, accompanied by the licensee, toured the interior and exterior of the facility, and inspected each room. The facility was clean and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Equipment inspected was in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 74 degrees Fahrenheit. Hot water temperature at sink accessible to clients measured at 121.4 degrees Fahrenheit and was adjusted during the visit.

Refrigerator and freezer temperatures were operational. 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 sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in a locked closet.


No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, and facility telephone were in working order. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in a visible area of the facility.

LPA interviewed staff who were present during the visit. The interviews did not raise any significant licensing concerns. Facility clients who were present during the visit are non-verbal. LPA reviewed records/files. Staff

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: TIZON'S PRIME CARE INC., #2
FACILITY NUMBER: 374604253
VISIT DATE: 11/20/2023
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
26
27
28
29
30
31
32
are current on training requirements. Client files contained required documents. Confidential records were stored in a locked area.

No deficiencies were cited during today's annual inspection.

An exit interview was conducted with Grace Cosico, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2