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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604265
Report Date: 12/17/2019
Date Signed: 01/06/2020 03:42:25 PM

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:AUTUMN VILLAS ON HONORS DRIVEFACILITY NUMBER:
374604265
ADMINISTRATOR:BEAN, KATIEFACILITY TYPE:
740
ADDRESS:5874 HONORS DRIVETELEPHONE:
(858) 750-2021
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 6DATE:
12/17/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Katie Bean, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Laarni Santiago conducted a Pre-Licensing and Component III visit to observe the facility for compliance with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. The LPA was met and granted entry into the facility by Katie Bean, Administrator. Also present during the visit is the current Administrator, Kendra Cole.

The LPA and administrator toured the physical plant, and LPA observed the following: resident accommodations, including furnishings, linens, and personal hygiene items; resident bathrooms were equipped with grab bars, non-skid mats, and water temperature measured at 118 and 111 degrees F in two bathrooms used by residents; resident, staff, and medication records are located in a locked cabinet; food service, including dishes, utensils, food storage, and a seven day supply of nonperishables and a two day supply of fresh perishables are present; toxic substances are stored in a locked cabinet in the garage to which access is locked; medication, first aid kit, and current first aid manual are stored in a locked cabinet and garage in the facility; activities, supplies and sufficient space in which to conduct activities are present; fire extinguisher is affixed with a current inspection tag; smoke and carbon monoxide detectors are present and operable; facility posting requirements are present in a common area at the hallway of the facility, and the administrator’s certification for Katie Bean expires January 14, 2021. According to the Administrator, there are no guns, weapons, or ammunition located on the facility property. No swimming pool or body of water was observed on the facility property.

LPA conducted Component III with Administrator, Katie Bean.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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: AUTUMN VILLAS ON HONORS DRIVE
FACILITY NUMBER: 374604265
VISIT DATE: 12/17/2019
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Items reviewed during the visit are in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations. Licensee was advised the application is pending management final review and approval. This report was discussed with the Administrator, and a copy of the report and Applicant Rights (LIC 9058) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
LIC809 (FAS) - (06/04)
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