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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604490
Report Date: 12/02/2021
Date Signed: 12/03/2021 11:14:08 AM

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:COLLEGE TOWN SENIOR RETIREMENT VILLA INCFACILITY NUMBER:
374604490
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:5252 STONE CTTELEPHONE:
(818) 445-1590
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:6CENSUS: 0DATE:
12/02/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Applicant Anna PetrosyanTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to Applicant Anna Petrosyan.

The facility fire clearance was granted on November 2, 2021 and reflects that the facility is approved for 6 residents, and that all 6 can be non-ambulatory.

During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 68 degrees F. Water temperatures at taps for resident use were compliant: Kitchen Faucet was 114.1 degrees F, Bathroom #1 was 115.3 degrees F, Bathroom #2 was 116.4 degrees F, and Bathroom #3 was 115 degrees F.

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future resident use. Refrigerator temperature was 40 degrees F, and freezer temperature was 0 degrees F.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: COLLEGE TOWN SENIOR RETIREMENT VILLA INC
FACILITY NUMBER: 374604490
VISIT DATE: 12/02/2021
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[CONTINUED FROM LIC809]

The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Per the applicant, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. 1 fire extinguisher and 1 complete first aid kit was present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit.

Petrosyan was advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicant, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
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