374604489-8-7-2023-08-AS-DNGN-CUH6B6-20230807203926

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604489
Report Date: 08/07/2023
Date Signed: 08/07/2023 08:39:49 PM

Document Has Been Signed on 08/07/2023 08:39 PM - 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:	AVALON PALM CARE, INC. DBA AVALON PALM		FACILITY NUMBER:	374604489
ADMINISTRATOR:	WINBLAD, JASON		FACILITY TYPE:	740
ADDRESS:	3271 INNUIT AVE		TELEPHONE:	(619) 757-3918
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:00 PM
MET WITH:	Caregiver Island Jen and Co-Administrator Magdarline Winblad		TIME COMPLETED:	08:45 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 Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to observe the physical plant. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Island Jen. LPA also spoke with Co-Administrator Magdarline Winblad via phone, during the visit. The Licensee previously submitted a written request to the CCLD San Diego Regional Office (RO) seeking to increase the facility's non-ambulatory capacity from four (4) residents to five (5) residents. The request did not involve changing the facility's bedridden capacity, which remains the same at one (1) resident. The request also did not involve changing the facility's total capacity, which remains the same at six (6) residents. The Licensee also submitted an updated facility sketch/floor plan, to reflect that the garage was legally converted into two rooms. On 07/23/2023, the local fire authority approved/granted an updated fire clearance, reflecting the facility was approved for six (6) residents in total, of which five (5) may be non-ambulatory and one (1) may be bedridden. The bedridden resident may reside in any room except for Bedroom #6, per the updated facility sketch. During today's visit, LPA toured the interior and exterior of the facility, observed residents, review medical records, and interviewed the co-administrator. Per LPA observation and review of the residents' LIC602 Physician's Reports: there were six (6) non-ambulatory residents, zero (0) ambulatory residents, and zero (0) bedridden residents in care. The updated facility sketch/floor plan was consistent with the current layout of the facility. The Licensee displayed comprehension of the terms of their new facility fire clearance. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AVALON PALM CARE, INC. DBA AVALON PALM	FACILITY NUMBER: 374604489
	VISIT DATE: 08/07/2023

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[CONTINUED FROM LIC 809]

No deficiencies were observed or cited during today's visit.

This portion of the application process has been completed. The Licensee will be sent an updated license to reflect the new fire clearance after CCLD management’s final review and approval.

An exit interview was conducted with Winblad. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her, via E-mail, during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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