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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604343
Report Date: 09/23/2020
Date Signed: 09/23/2020 10:51:11 AM

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:CARABELLE SENIORS HOMEFACILITY NUMBER:
374604343
ADMINISTRATOR:DIO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:920 SACRAMENTO AVE.TELEPHONE:
(619) 713-1137
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 0DATE:
09/23/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Josephine Dio, AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted a virtual visit via FaceTime to perform the Pre-licensing inspection, due to COVID-19. LPA identified herself and spoke with Administrator Josephine Dio. The purpose of today’s virtual inspection is to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. Facility is approved to serve six (6) elderly residents, in which one (1) resident may be bedridden.

During the inspection, the Administrator provided a virtual tour of the facility. LPA observed the facility to be clean, and in good repair with no pathway obstruction. The resident's bedrooms, bathrooms and common areas were inspected and found to be in compliance. All required postings were posted in the front hallway. There was a sufficient food supply observed. Administrator Certificate expires on 09/11/2021 for Josephine Dio. The facility does not have firearm and/or ammunition on grounds. There is no pool on the facility grounds. The fire inspection was approved on 07/06/2020.

CCLD has completed the virtual Pre-licensing inspection, Comp III was provided. CCLD management was informed of the findings of the inspection. Final review and approval is pending with the Application Bureau.

An exit interview was conducted with Administrator Josephine Dio and the Licensee’s Rights (LIC 9058 01/15) along with a copy of this report was provided to the Dio via email. A reply email or return receipt from the Administrator will confirm receipt of documents.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020
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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