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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604288
Report Date: 05/23/2022
Date Signed: 05/23/2022 10:51:23 AM


Document Has Been Signed on 05/23/2022 10:51 AM - 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:CADENCE AT POWAY GARDENS - THE PALMSFACILITY NUMBER:
374604288
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12708 MONTE VISTA RDTELEPHONE:
(858) 312-8492
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:24CENSUS: 14DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ikhdar RasasTIME COMPLETED:
10:54 AM
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Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Medication Care Partner Ikhdar Rasas and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

An exit interview was conducted with Ikhdar Rasas, A copy of this report along with Licensee Rights (LIC 9098, 01/16) was provided to Ikhdar Rasas whose signature below verifies receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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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