374604422-7-26-2021-08-AS-LSAO-C5ARW8-20210726132244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604422
Report Date: 07/09/2021
Date Signed: 07/26/2021 01:27:01 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:	LA JOLLA CASA PACIFICA		FACILITY NUMBER:	374604422
ADMINISTRATOR:	FERNANDEZ, JENNIFER		FACILITY TYPE:	740
ADDRESS:	5468 PACIFICIA DR		TELEPHONE:	(858) 775-6935
CITY:	LA JOLLA	STATE: CA	ZIP CODE:	92037
CAPACITY:	6	CENSUS: 6	DATE:	07/09/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Jennifer Fernandez, Applicant		TIME COMPLETED:	01:10 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) Laarni Santiago conducted an announced Pre-licensing and Component IIl visit to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. LPA Santiago identified herself to Applicant, Jennifer Fernandez and explained the purpose of the visit. The fire inspection was completed on February 25, 2021 by the San Diego Fire Department. Facility was cleared for six residents ages 60 and above, five (5) that may be non-ambulatory, and one (1) of which may be bedridden in dedicated bedroom only. Hospice Waiver approved for 2 residents. During today's visit LPA Santiago, accompanied by Applicant, Jennifer Fernandez, conducted a tour of the facility. According to Applicant, there will be no firearms or ammunition stored on site. No pools or bodies of water were observed. Indoor and outdoor passageways are free from obstructions. All window screens are clean and in good repair. Hallways are well-lit and night lights are available in the hallways. Fire smoke alarms, and carbon monoxide detectors were all observed and operational. There is a bed for each resident's bedroom, equipped with padded covered mattresses, and pillows, observed clean and in good repair. There is sufficient closet and drawer space for resident belongings. Each resident bedroom is furnished with a chair, lamp, and a night stand. Resident bathrooms are also in good repair; equipped with handrails; showers were equipped with non-skid shower mats. The facility maintains a sufficient supply of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, hand towels, and washcloths. LPA Santiago observed a seven-day supply of non-perishable foods and 2 day supply of perishables. The facility kitchen also maintains sufficient amounts of clean utensils, and equipment for proper storage of food items, and locked storage for sharp items. LPA Santiago observed an area for confidential storage area for personnel and resident records, as well as a locked storage cabinet for residents' medications. There is a shaded outdoor activity space, a common room available for visitors, and appropriate activity supplies.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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: LA JOLLA CASA PACIFICA	FACILITY NUMBER: 374604422
	VISIT DATE: 07/09/2021

NARRATIVE

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LPA observed a first aid kit maintained at the facility. The facility garage remains locked when not in use, and also has a locked area to store cleaning/laundry supplies and other toxic chemicals. There is emergency lighting and supplies readily available for safety measures. The hot water temperature measured with in compliance (111 to 115 degrees F) in facility bathrooms. Applicant Fernandez's Administrator's Certification expires on July 29, 2021

Component III was conducted at the facility with applicant Fernandez. LPA Santiago reviewed continuing operational requirements, as well as record keeping and physical plant compliance. The applicant shall contact the Centralized Application Bureau (CAB) for completion of this pending facility application. Based on today's evaluation, the facility is in compliance with CCR, Title 22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing inspection is complete and the 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 Applicant's e-mail address. An electronic mail read receipt confirms delivery and receipt of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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