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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604532
Report Date: 04/07/2022
Date Signed: 04/07/2022 02:39:02 PM

Document Has Been Signed on 04/07/2022 02:39 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:ROJA HOUSEFACILITY NUMBER:
374604532
ADMINISTRATOR:GILBO, JACKELINEFACILITY TYPE:
735
ADDRESS:4944 ROJA DRIVETELEPHONE:
(760) 277-3920
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 0DATE:
04/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Jackeline Gilbo, ApplicantTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an announced Pre-Licensing visit. LPA was met by Applicants, Alex Rodriguez and Jackeline Gilbo, and granted entry into the facility. The purpose of today’s visit was to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on January 13, 2022, and the facility was approved for 6 ambulatory clients.

During today's visit, LPA, accompanied by applicants, toured the facility inside and outside and inspected every room. The facility was found to be in good repair with no pathway obstructions. Clients' bedrooms were observed to be clean and contained required furnishings. Toilets were found to be in working order. Facility temperature was 74 degrees F during the visit. Hot water temperature in client bathrooms measured at 117 and 115 degrees F. Hazardous and/or toxic chemicals were stored and secured in locked cabinets that are inaccessible to clients. There were locked closets for storage of medications and client and staff records. There was a first aid kit present in the facility. Activities and sufficient space in which to conduct activities were present. Fire extinguishers were observed in the facility. Hard-wired smoke and carbon monoxide detectors were present and were recently inspected by the local fire authority. No pools or bodies of water were observed near or on the premises. According to the applicants, no firearms and/or ammunition were present or will be stored in the facility. Non-perishable food items were present and appropriately stored in the facility. LPA conducted Component III with the applicants. The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance.

Pre-Licensing is complete, and no deficiencies were observed during the visit. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted, and a copy of this report was provided to applicants, via email, following the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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