374604505-3-1-2022-08-AS-DNGN-CC4QKU-20220301111453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604505
Report Date: 02/10/2022
Date Signed: 03/01/2022 11:15:30 AM

Document Has Been Signed on 03/01/2022 11:15 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	UC SENIOR CARE IV		FACILITY NUMBER:	374604505
ADMINISTRATOR:	KELLY, FLORA		FACILITY TYPE:	740
ADDRESS:	3810 GOVERNOR DRIVE		TELEPHONE:	(858) 583-6431
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	6	CENSUS: 4	DATE:	02/10/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Applicant Kelly Flora and Staff Kevin Posada		TIME COMPLETED:	04:30 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 announced Pre-Licensing visit to observe the facility’s physical plant and records 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 Kelly Flora and staff Kevin Posada. The facility fire clearance was granted on November 8, 2021, and reflects that the facility is approved for six (6) residents, all of whom may 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 76 degrees F. Water temperatures were complaint at all taps: kitchen was 113.5 F, while bathrooms were 114.6 F, 111.4 F, and 114.6 F, respectively. The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for resident use. Refrigerator temperature was 38 F, and freezer temperature was 0 F. 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 resident 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 residents. Per the applicant, no firearms or ammunition are or will be stored at the facility. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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: UC SENIOR CARE IV	FACILITY NUMBER: 374604505
	VISIT DATE: 02/10/2022

NARRATIVE

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[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all operational. One fire extinguisher and one complete first aid kit were 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 California Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. The applicant was advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with Flora and Posada. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to the applicant via E-mail.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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