374604481-10-20-2023-08-AS-RSEO-CWSQ6U-20231020115407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604481
Report Date: 10/20/2023
Date Signed: 10/20/2023 11:54:39 AM

Document Has Been Signed on 10/20/2023 11:54 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	COLUMBIA RESIDENTIAL CARE LLC		FACILITY NUMBER:	374604481
ADMINISTRATOR:	CHANEL BERNARTE		FACILITY TYPE:	735
ADDRESS:	1610 COLUMBIA STREET		TELEPHONE:	(858) 294-3670
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY: 4		CENSUS: 3	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Chanel Bernarte		TIME COMPLETED:	12:14 PM

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was allowed entry and discussed the purpose of the visit with Licensee Chanel Bernarte. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom zero (0) can be non-ambulatory. During today’s inspection there were two (2) clients present in the facility.

LPA, accompanied by licensee, 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, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

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. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas.

No pools or bodies of water on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: COLUMBIA RESIDENTIAL CARE LLC	FACILITY NUMBER: 374604481
	VISIT DATE: 10/20/2023

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[CONTINUED FROM LIC 809]

LPA interviewed staff and client. LPA reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Caregiver Cody Smith whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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