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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604452
Report Date: 10/19/2021
Date Signed: 10/19/2021 12:02:18 PM

Document Has Been Signed on 10/19/2021 12:02 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MISSION CAREHOME SOUTHFACILITY NUMBER:
374604452
ADMINISTRATOR:LIMPIN, ROSEMARIEFACILITY TYPE:
740
ADDRESS:2534 NYE STTELEPHONE:
(619) 777-9674
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY: 6CENSUS: 0DATE:
10/19/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Alexander Limpin, ApplicantTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Carmen Lopez conducted a follow-up announced Pre-Licensing inspection at the facility. The initial Pre-Licensing visit was conducted on August 27, 2021. Component III was included during today’s pre-licensing inspection for the pre-licensing inspection of Mission Carehome North, 374604453. LPA Lopez identified herself to Applicant, Alexander Limpin and explained the purpose of the visit was to ensure Title 22 compliance for the initial licensure. The facility plans to serve six (6) Residential Care Facility for the Elderly (RCFE), ages 60 and older. The fire clearance was granted by City of San Diego Fire - Rescue Department, letter dated May 18, 2021. A copy of the letter was submitted to the Department during today's inspection.

LPA Lopez observed the areas of correction to include; facility utilities are cleaned and in working condition; a secured locked cabinet’s for medications and hazardous items was observed and a secured cabinet for facility records was observed; Printed plan of Operations is accessible for the facility; linen and food storage is accessible indoors.

Items reviewed during the visit were in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations. The Applicant was advised that the application is pending management final review and approval. A copy of this report and Appeal Rights (LIC 9058) were provided to the Applicant via electronic mail. An electronic mail read receipt confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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