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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604479
Report Date: 11/30/2023
Date Signed: 11/30/2023 11:43:28 AM

Document Has Been Signed on 11/30/2023 11:43 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:MENTAL HEALTH CENTER OF SAN DIEGO LLCFACILITY NUMBER:
374604479
ADMINISTRATOR:CARMONA, GILBERTFACILITY TYPE:
772
ADDRESS:3825 BEN ST.TELEPHONE:
(858) 258-9883
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY: 6CENSUS: 5DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Pravesh Potla, Program DirectorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Lead Behavioral Health Technician, Carlos Millan. LPA met with Pravesh Potla, Program Director, who arrived later during the visit.

According to the facility’s license, the facility serves as a short-term crisis residential program. The maximum capacity is six (6) ambulatory adult clients. The facility sketch was accurate to the 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. LPA interviewed staff and clients, and reviewed staff and client records/files. The interviews did not raise any licensing concerns.

LPA 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. Client 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 and recorded at 68 degrees, Fahrenheit.

LPA observed via measurement with a thermometer device that hot water temperature at taps accessible to clients were compliant: Kitchen was 113.0 and client bathroom was 111.3, degrees, Fahrenheit. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored.

Cooking/dining equipment and utensils were present. Medications were labeled, as required, and secured. Smoke alarms, carbon monoxide detectors 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
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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: MENTAL HEALTH CENTER OF SAN DIEGO LLC
FACILITY NUMBER: 374604479
VISIT DATE: 11/30/2023
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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.

No deficiencies were cited during today’s visit. An exit interview was conducted with Mr. Potla and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to Mr. Potla.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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