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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604328
Report Date: 09/13/2024
Date Signed: 09/13/2024 12:44:48 PM


Document Has Been Signed on 09/13/2024 12:44 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:UC CARE SENIOR LIVING IFACILITY NUMBER:
374604328
ADMINISTRATOR:DEREK POSADAFACILITY TYPE:
740
ADDRESS:3664 GOVERNOR DRTELEPHONE:
(858) 750-3455
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 5DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Flora KellyTIME COMPLETED:
12:55 PM
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Licensing Program Analysts (LPAs), Sabel Martinez and Hannah Rodgers, conducted an unannounced Required Annual Inspection visit. The LPAs identified themselves to, and discussed the purpose of the visit with caregiver Laura Olmos. Administrator Flora Kelly and Caregiver Beatriz Jimenez arrived during the visit and assisted the LPAs. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility was also approved a hospice waiver for five (5) residents.

The LPAs, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were 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.

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 toxic chemicals/poisons accessible to clients. The LPAs observed centrally stored medications.



No pools, nor bodies of water on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. A fire extinguisher, and first aid kit were readily accessible. Required licensing postings were observed in visible areas of the facility.

The LPAs interviewed staff and reviewed multiple staff and client records/files. The files which LPAs reviewed contained required documents. Technical advise was provided to maintain compliance, including clearing pathways, and medication storage. No deficiencies were cited during today's annual inspection.

An exit interview was conducted with Administrator Kelly and Jimenez, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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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