374604308-8-3-2020-08-AS-AVOO-BS5RYV-20200803132646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604308
Report Date: 07/22/2020
Date Signed: 08/03/2020 01:26:57 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:	CARLOVY HOMES IN CARLSBAD		FACILITY NUMBER:	374604308
ADMINISTRATOR:	CHUNG, JAMES		FACILITY TYPE:	740
ADDRESS:	1275 CYNTHIA LANE		TELEPHONE:	(623) 341-2794
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	6	CENSUS: 4	DATE:	07/22/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensee, James Chung		TIME COMPLETED:	12:45 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), Alexandre Vo, conducted an announced Pre-licensing and Component III virtual visit for a Change of Ownership Application to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. The visit was conducted via WhatsApp due to COVID-19. LPA was joined by Licensee, Dr. James Chung, and Administrator, Ana Radovic. LPA identified himself and explained the purpose of the virtual call. Licensee's application is to serve six (6) elderly residents, ages 60 and above, three (3) of whom may be non-ambulatory. Fire clearance was granted on February 18th, 2020. There is a hospice waiver for three (3) residents, including care plans for Restricted Health Conditions. During today's visit, LPA virtually toured the facility, accompanied by facility representatives. According to Licensee, there will be no firearms or ammunition stored on site. No pools or bodies of water were observed. Indoor and outdoor passage ways are free from obstructions. All window screens are clean and in good repair. Hallways and stairwells are well-lit and night lights are available in the hallways. Fire, smoke alarms, and carbon monoxide detectors are operational. There is a bed for each resident with a mattress, mattress pad, bedsprings, and pillows, which are clean and in good repair. There is sufficient closet and drawer space. Resident bedrooms are furnished with a chair and lamp for each resident, and a night stand for every two residents. Residents' bathrooms are located near their bedrooms and there is sufficient hygiene products for personal use; clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, hand towels, and washcloths are sufficient in supply. Facility has a seven-day supply of non-perishable foods and a two-day supply of perishable foods. There is sufficient amount of clean utensils and equipment for proper storage of food items. There is confidential storage area for personnel and resident records. There is a locked storage area for residents' medications and a locked storage area for chemicals. Emergency exit plans, facility policy, residents' personal rights are posted in prominent areas. There is a shaded outdoor activity space, common room available for visitors, and appropriate activity supplies.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2020

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: CARLOVY HOMES IN CARLSBAD	FACILITY NUMBER: 374604308
	VISIT DATE: 07/22/2020

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

First aid kit and manual are maintained . There is space and equipment available for laundry. There is an operating telephone line. There is emergency lighting and supplies. Vehicles used to transport residents are in safe operating condition. Hot water temperature was measured at 105 degrees F, and facility temperature was set at 72 degrees F. Administrator, Ana Radovic, certification expires on February 6th, 2021. Certificate of liability insurance is on file.

Component III was completed with the facility representatives via Zoom. Based on today's evaluation, facility is in compliance with CCR, T22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing is complete and facility has no deficiencies.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Licensee's e-mail address. An electronic mail read receipt confirms delivery of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2