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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604388
Report Date: 02/02/2021
Date Signed: 02/02/2021 01:12:33 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:SUNSET CLIFFS ELDER CAREFACILITY NUMBER:
374604388
ADMINISTRATOR:RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:1039 SANTA BARBARA STREETTELEPHONE:
(619) 791-5495
CITY:SAN DIEGOSTATE: CAZIP CODE:
92107
CAPACITY:6CENSUS: 0DATE:
02/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Gaurav Rathi, Administrator
TIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Daniel Pena, conducted an announced virtual Pre-Licensing/Component III inspection due to COVID-19. Using FaceTime video application, LPA identified himself to Administrator Gaurav Rathi and explained the purpose of the visit which was to evaluate Title 22 compliance for the initial application of initial licensure. The facility plans to serve six (6) residents ages 60 and above. On 12/24/20, the San Diego Fire Department approved the Fire Clearance for the facility to serve five (5) non-ambulatory and one (1) bedridden resident. Per the Fire Clearance, a bedridden resident may be assigned to Room One or Two. The facility also intends to serve residents with Dementia.

An inspection of the facility was conducted inside and out. The facility has six (6) resident rooms and one (1) bathroom for resident use. Bathrooms are equipped with toilets, hand washing and bathing facilities which are sanitary and in operating condition. Water temperature 108.8 F for the resident bathroom. All lighting fixtures and facility windows were operable and in good condition. A nightlight was present in the hallway leading to the restroom.

Outdoor and indoor passageways were free from obstructions. Fire extinguishers were affixed with current tags. Smoke and carbon monoxide detectors were present and operational. LPA observed no pools or other bodies of water on the premises. Locked cabinets and storage areas were identified to store toxic substances, knives, and medication. Hazardous items were stored such that they were inaccessible to residents. Per Administrator, no weapons or ammunition are or will be stored at the facility.

LPA observed facility accommodations including food supplies, medication storage, first aid kit as well as toiletries and linens. Required CCLD postings were present. LPA
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021
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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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: SUNSET CLIFFS ELDER CARE
FACILITY NUMBER: 374604388
VISIT DATE: 02/02/2021
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discussed the RCFE Comp III with Administrator Rathi for continuing operational requirements, record keeping, reporting requirements and physical plant compliance. Administrator Rathi’s certification is current through October 3, 2021.

The facility is ready for licensure pending management approval. LPA advised Rathi to notify CCLD within five (5) days of accepting their first resident. An exit interview was conducted with Administrator Rathi. A copy of this report along with the licensee Appeal Rights (LIC 9058 01/16) was provided via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021
LIC809 (FAS) - (06/04)
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