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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604525
Report Date: 01/29/2024
Date Signed: 01/29/2024 02:43:36 PM


Document Has Been Signed on 01/29/2024 02:43 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:CANYON GUEST HOMEFACILITY NUMBER:
374604525
ADMINISTRATOR:RAPHAEL, DANIELFACILITY TYPE:
740
ADDRESS:4224 EMET COURTTELEPHONE:
(858) 285-0811
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:6CENSUS: 6DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Caregivers Marilou Delapena and Eva EstanolTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA identified himself and disclosed the purpose of the visit to Caregivers Marilou Delapena and Eva Estanol. The facility was Licensed for a capacity of six (6) non-ambulatory residents, with a hospice waiver of five (5).

The LPA, accompanied by caregiver, 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 and slip hazards. Resident bedrooms
contained the required furnishings. The facility had extra linens, sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in locked areas.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors were operational. Facility telephone, a fire extinguisher, and a first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The LPA interviewed staff and reviewed multiple staff and client records/files.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Caregiver Delapena, 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: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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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