374604388-1-30-2024-08-AS-DPEA-CZYSKH-20240130125647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604388
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:56:52 PM

Document Has Been Signed on 01/30/2024 12:56 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:	SUNSET CLIFFS ELDER CARE		FACILITY NUMBER:	374604388
ADMINISTRATOR:	TRAVONNA WASHINGTON		FACILITY TYPE:	740
ADDRESS:	1039 SANTA BARBARA STREET		TELEPHONE:	(619) 791-5495
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92107
CAPACITY:	6	CENSUS: 6	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Travonna Washington, Co-Administrator & Gaurav Rathi, Administrator		TIME COMPLETED:	12:30 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	On 1/30/2024, at about 10:05 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Travonna Washington, Co-Administrator. Gaurav Rathi, Administrator, later joined LPA for the inspection. According to the facility’s license, the age range is 60 and over; approved for capacity of six (6) non-ambulatory residents; of which one (1) may be bedridden; approved for hospice waiver for three (3) residents. On the day of the inspection four of six residents were ambulatory. During the inspection, LPA toured the interior and exterior of the facility and observed each resident’s room. The facility was organized, kempt and in good repair. Pathways inside the property were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, 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 resident activities. There was at least two days of perishable food, and at least seven days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per Administrator, Rathi, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Hot water temperatures measured in the resident restroom and kitchen recorded at 111.1 and 112.7, degrees Fahrenheit which are both within Title 22 Regulations. LPA interviewed residents and reviewed staff and resident records/files. LPA interviews did not raise any licensing concerns.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSET CLIFFS ELDER CARE	FACILITY NUMBER: 374604388
	VISIT DATE: 01/30/2024

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The files which LPA reviewed contained the required documents. LPA reviewed the facility's Infection Control Plan and did not note any concerns. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Administrator, Rathi to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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