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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604501
Report Date: 12/22/2021
Date Signed: 12/22/2021 05:24:31 PM

Document Has Been Signed on 12/22/2021 05:24 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:DEL REY SPRINGSFACILITY NUMBER:
374604501
ADMINISTRATOR:GONZALEZ, EDUARDOFACILITY TYPE:
735
ADDRESS:1181 PLAZA AMPARADATELEPHONE:
(619) 990-8870
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 4CENSUS: 0DATE:
12/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Elizabeth Rivera, Facility ManagerTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an announced Pre-Licensing and Component III inspection at an Adult Residential Facility for a change of location on today's date to inspect the facility for compliance with Title 22, Division 6, Chapter 8 of the California Code of Regulations and the Health & Safety Code. After arriving at the facility, LPA identified herself, disclosed the purpose of the visit and was granted entry by Elizabeth Rivera, Facility Manager.

LPA toured the physical plant, inside and out, and observed the following: Resident accommodations will be brought in with the clients from the former facility along with the furnishings, linens, and personal hygiene items; resident bathrooms will be equipped with non-skid flooring; water temperatures were measured at: downstairs bathroom- 118 degrees Fahrenheit (F); Kitchen faucet – 116.2 degrees F; upstairs shared bathroom 115.2 degrees F; master bedroom sink – 114.1 degrees F; the facility’s ambient room temperature was 75 degrees F at the time of the visit; medications will be stored in a locked cabinet located in the dining area. Sharps objects will be in the same locked cabinet in a different drawer. Staff and resident records will be kept in a secured cabinet in the office area located in the main living room; Food service including dishes, utensils, food storage, and a seven (7) day supply of non-perishables; the two (2) day supply of perishables will be brought over from the former facility once required approval is met. Toxic substances will be stored in a locked cabinet in the garage; first aid kit with required supplies and first aid manual were purchased and will be stored in one of the drawers inside the locked medication cabinet. Activity supplies will be brought over from former facility and placed in the family room area. There is sufficient space in which to conduct activities; fire extinguishers were present; smoke and carbon monoxide detectors were present and operable; required facility postings were present and visible in the common area of the facility.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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: DEL REY SPRINGS
FACILITY NUMBER: 374604501
VISIT DATE: 12/22/2021
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According to the Manager, there are no guns, weapons, or ammunition stored on the facility property. The facility does not have a swimming pool or bodies of water. The fire place will not be used and does have a lock on the handles.

LPA conducted and completed the Component III with Facility Manger Rivera during the visit. LPA verified her understanding of Title 22 continuing requirements, including physical environment, reporting requirements, personnel and resident records, incidental medical care, health related services and activities.

No deficiencies were observed during today's visit as all items reviewed during the visit are in compliance with Title 22, Division 6, Chapter 8 of the California Code of Regulations and the Health and Safety Code. The Licensee was advised that the application is pending management final review and approval. An exit interview was conducted with Facility Manager Rivera and a copy of this report and Applicant Rights (LIC 9058) was provided to License Eduardo Gonzalez via electronic mail; an email receipt confirms the receipt these documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
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