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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604489
Report Date: 12/26/2023
Date Signed: 12/26/2023 01:43:31 PM


Document Has Been Signed on 12/26/2023 01:43 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:AVALON PALM CARE, INC. DBA AVALON PALMFACILITY NUMBER:
374604489
ADMINISTRATOR:WINBLAD, JASONFACILITY TYPE:
740
ADDRESS:3271 INNUIT AVETELEPHONE:
(619) 757-3918
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:6CENSUS: 6DATE:
12/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Administrator Magdarline Winblad and Caregiver Malia SamuelaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Malia Samuela. Administrator Magdarline Winblad arrived during the visit and assisted the LPA.

The facility file reflected the facility was licensed for four (4) non-ambulatory residents in rooms 1-4, one (1) bedridden in room # 5, and one ambulatory resident in room # 6. A review of documents and the Field Automation System (FAS), revealed the Department received an updated fire clearance, received a request for non- ambulatory increase, and the Department conducted a Case Management visit on 8/7/23.

During today's visit, the 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. Resident bedrooms contained the required furnishings

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in a locked area.



No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Smoke detectors, fire extinguisher(s), a first aid kit, and required licensing postings were observed in visible area of the facility.

The LPA interviewed staff and reviewed multiple staff and client records/files. The files which LPA reviewed contained required documents.
No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Administrator Winblad, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
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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