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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604483
Report Date: 06/03/2024
Date Signed: 06/03/2024 11:51:15 AM


Document Has Been Signed on 06/03/2024 11:51 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:SHORESIDE VILLA ASSISTED LIVINGFACILITY NUMBER:
374604483
ADMINISTRATOR:KAHNIS, KEVINFACILITY TYPE:
740
ADDRESS:1911 S FREEMAN STTELEPHONE:
(442) 266-2107
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:3CENSUS: 3DATE:
06/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Erika Torres AvalosTIME COMPLETED:
11:50 PM
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Licensing Program Analyst (LPA) Ryan Fulton and licensing Program Manager (LPM) Jennifer Lott conducted an unannounced Case Management visit. LPA and LPM were greeted at the front door by Erika Torres Avalos and granted entry after identifying themselves and disclosing the purpose of their visit. The purpose of the LPA and LPM visit was to discuss the licensee’s request for a change in ambulatory status.

LPA and LPM met with Erika Torres Avalos and conducted a tour of the facility. LPA and LPM inspected the facility bedrooms # 1 and 2 that were granted as non-ambulatory fire clearance status on 05/01/2024 by Oceanside fire department.

LPA and LPM found the physical plant to be consistent with the submitted facility sketch/floor plan. Facility grounds and identified resident bedrooms meet title 22 Personal Accommodations and Services requirements.

License will be updated to reflect the change in ambulatory status and will follow under a separate cover.

An exit interview was conducted, a copy of this report along with a copy of the licensee rights (LIC9058 03/22) were provided to Caregiver, Erika Torres Avalos whose signature below confirms receipt

SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -76-2311
LICENSING EVALUATOR NAME: Ryan FultonTELEPHONE: 619-629-8938
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
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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