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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604593
Report Date: 05/24/2023
Date Signed: 05/26/2023 12:16:19 PM


Document Has Been Signed on 05/26/2023 12:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/26/2023 12:14 PM

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

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to observe the physical plant. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Masho Gebrehiwot.

The Licensee previously submitted a written request to the CCLD San Diego Regional Office seeking to increase the facility's non-ambulatory resident capacity from two (2) residents to four (4) residents. This request did not involve changing the facility's total capacity, which remains the same/unchanged at six (6) residents.



On 05-03-2023, the local fire authority granted an updated fire clearance, reflecting the facility was approved for six (6) residents in total, of which four (4) residents may be non-ambulatory, and none may be bedridden. This fire clearance specified that non-ambulatory residents may only be assigned to the facility's "16.8 x 17.7" ft bedroom and the "12.8 x 13.6" ft bedroom, and not the facility's "10.2 x 15.3" ft bedroom.

During today's visit, the facility census was zero (0); there were no residents s in care. LPA toured the interior and exterior of the facility and interviewed the licensee, who displayed comprehension of the specific terms of the facility's new fire clearance. The facility's current sketch/floor plan was consistent with the current layout of the facility.

No deficiencies were observed or cited during today's visit.

This portion of the application process has been completed. The Licensee will be sent an updated license to reflect the new fire clearance after CCLD management’s final review and approval.

An exit interview was conducted with Gebrehiwot, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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