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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604306
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:29:30 PM


Document Has Been Signed on 05/15/2024 04:29 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:DALEINA'S HOME CAREFACILITY NUMBER:
374604306
ADMINISTRATOR:CARMONA, CARINA B.FACILITY TYPE:
740
ADDRESS:815 ARCADIA PLACETELEPHONE:
(619) 475-3561
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:6CENSUS: 6DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Carina CarmonaTIME COMPLETED:
04:30 PM
NARRATIVE
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Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Visitacion Cabbab. Administrator Carina Carmona later arrived to meet with LPA The facility is currently licensed for a maximum capacity of six (6) clients, of which six (6) may be non-ambulatory. During today’s inspection, there was a total of six (6) clients in care.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens, hygiene supplies were present and personal protective equipment were present. Hot water temperature was compliant.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per staff no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) and first aid kit was present. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. The files which LPA reviewed contained required documents.

No deficiencies were cited during today's annual inspection; however, technical violations and advisories were issued. An exit interview was conducted with Carmona to whom copies of this report, LIC 9102TV Technical Violations, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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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