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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604582
Report Date: 08/05/2022
Date Signed: 08/05/2022 10:27:59 AM

Document Has Been Signed on 08/05/2022 10:27 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:UNIVERSAL HOMES IIIFACILITY NUMBER:
374604582
ADMINISTRATOR:BAUTISTA, EMMANUELFACILITY TYPE:
735
ADDRESS:1189 FIRST AVENUETELEPHONE:
(619) 299-7878
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 0DATE:
08/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Applicant, Emmanual Bautista, House Manager, Lupita Perez and Secretary Yoanne CrisostomoTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton, conducted an announced Pre-Licensing/Component III inspection at the facility. LPA was greeted at the front door by Secretary, Yoanne Crisostomo and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit to Applicant, Emmanuel Bautista, House Manager, Lupita Perez and Secretary Yoanne Crisostomo which was to evaluate Title 22 compliance for the initial application of initial licensure. The facility plans to serve four (4) developmentally disabled adults, ages 18-59; all of whom are ambulatory. The fire clearance was granted by Chula Vista Fire Department on May 13, 2022.

An inspection of the facility was conducted inside and out. The facility has client (2) client bedrooms and one (1) bathroom for client use. Client bathroom is equipped with a toilet, hand washing and bathing facilities which are sanitary and in operating condition. All lighting fixtures and facility windows were operable and in good condition. A light was present in the hallway leading to the restroom.

Indoor and outdoor passageways were free from obstructions. Fire extinguisher, smoke and carbon monoxide detectors were present and operational. LPA observed no pools or other bodies of water on the premises. Locked cabinets and storage areas were identified to store toxic substances and medication. Hazardous items were stored such that they were inaccessible to clients. Applicant reports there are no firearms or weapons stored at the facility.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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: UNIVERSAL HOMES III
FACILITY NUMBER: 374604582
VISIT DATE: 08/05/2022
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Client and Staff records are stored in a locked room and made confidential. LPA observed facility accommodations including food service, dishes and food storage were observed as well as a first aid kit. Activities and sufficient space in which to conduct activities were present. Facility had sufficient linens. Required CCLD postings were present. LPA discussed the ARF Component III with Applicant, Emmanuel Bautista, House Manager, Lupita Perez and Secretary Yoanne Crisostomo for continuing operational requirements, record keeping, reporting requirements and physical plant compliance. Applicant’s Administrator Certification is current through October 30, 2023.

Items reviewed during the visit were not in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations at this time. Therefore, another Pre-Licensing visit will be required and scheduled. This is to ensure compliance with the following: water temperature will be verified, a working telephone will be on the premises and excess personal property removed from client bedrooms. An exit interview was conducted with Applicant, Bautista. A copy of this report along with the licensee Appeal Rights (LIC 9058 01/16) was provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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