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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604582
Report Date: 08/18/2022
Date Signed: 08/18/2022 09:22:55 AM

Document Has Been Signed on 08/18/2022 09:22 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:
08/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Applicant, Emmanual Bautista and Secretary Yoanne CrisostomoTIME COMPLETED:
09:28 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted a follow-up announced Pre-Licensing inspection at the facility. The initial Pre-Licensing visit was conducted on August 5, 2022, which included the Component III. LPA was greeted at the front door by Applicant, Emmanual Bautista and Secretary Yoanne Crisostomo and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit 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.

LPA Hamilton observed the areas of correction to include; a working telephone present on the premises, excess personal property was removed from client bedrooms and water temperature measured 106.0 degrees Fahrenheit.

Items reviewed during the visit were in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations. The Applicant was advised that the application is pending management final review and approval. A copy of this report and Appeal Rights (LIC 9058) were provided to the Applicant.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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