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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604456
Report Date: 03/04/2022
Date Signed: 03/07/2022 07:23:09 AM


Document Has Been Signed on 03/07/2022 07:23 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SAY YOU'RE HOMEFACILITY NUMBER:
374604456
ADMINISTRATOR:SAYRE, LISA HENDERLINGFACILITY TYPE:
740
ADDRESS:5971 LAKE MURRAY BLVD.TELEPHONE:
(619) 249-4114
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 3DATE:
03/04/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Applicant Lisa SayreTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to applicant Lisa Sayre.

The facility fire clearance was granted on May 19, 2021 and reflects that the facility is approved for six (6) residents, and that all may be non-ambulatory.

During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 73 degrees F. Water temperatures were compliant as follows: Kitchen was 109.8 degrees F, Bathroom #1 was 109.6 degrees F, Bathroom #2 was 108 degrees F, Bathroom #3 was 108 degrees F, and Bathroom #4 was 107.2 degrees F.

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future resident use. Refrigerator temperature was 38 degrees F, and freezer temperature was 0 degrees F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential resident and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Tellez LizzetteTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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: SAY YOU'RE HOME
FACILITY NUMBER: 374604456
VISIT DATE: 03/04/2022
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[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Two (2) fire extinguishers and one complete first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Sayre was advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicant, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISOR'S NAME: Tellez LizzetteTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
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