374604452-11-30-2023-08-AS-DPEA-CY3R7D-20231130114611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604452
Report Date: 11/29/2023
Date Signed: 11/30/2023 11:46:16 AM

Document Has Been Signed on 11/30/2023 11:46 AM - 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:	MISSION CAREHOME SOUTH		FACILITY NUMBER:	374604452
ADMINISTRATOR:	LIMPIN, ROSEMARIE		FACILITY TYPE:	740
ADDRESS:	2534 NYE ST		TELEPHONE:	(619) 777-9674
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92111
CAPACITY:	6	CENSUS: 4	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Caregiver Emerita Montalla & Alexander Limpin, Manager/Director		TIME COMPLETED:	04:00 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 Analysts (LPAs) Daniel Pena and Mark Mandel conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Emerita Montalla. LPAs later met with Alexander Limpin, Manager, who arrived later during the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents, age range 60 and over six (6) non-ambulatory of which, one (1) may be bedridden. Hospice waiver for three (3). On day of visit, there were two residents on Hospice. During today’s inspection, there were a total of four (4) residents in care, of which one (1) was non-ambulatory, and none were bedridden. These non-ambulatory clients were each assigned to bedrooms which had glass doors leading directly outside, consistent with the facility sketch. The facility sketch was accurate to the current layout of the facility. This facility does not feature a secured perimeter or delayed egress doors. Required licensing postings were observed in visible areas of the facility. LPAs, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens, and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable. LPAs observed via measurement with a thermometer device hot water temperature at taps accessible to residents were compliant: Kitchen was 112.3 F. and resident bathroom was 107.8 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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: MISSION CAREHOME SOUTH	FACILITY NUMBER: 374604452
	VISIT DATE: 11/29/2023

NARRATIVE

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and utensils were present. Medications were labeled, as required, and secured. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility.
LPAs interviewed staff and clients, and reviewed staff and client records/files. The interviews did not raise any licensing concerns.

No deficiencies were cited during today’s visit. An exit interview was conducted with Mr. Limpin and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to Mr. Limpin.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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