374604614-2-9-2023-08-AS-DNGN-CNVRC9-20230209115358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604614
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:54:04 AM

Document Has Been Signed on 02/09/2023 11:54 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:	ANABELLAHOMECARE		FACILITY NUMBER:	374604614
ADMINISTRATOR:	CHERRY COOK		FACILITY TYPE:	740
ADDRESS:	14249 HIGH VALLEY		TELEPHONE:	(406) 998-8022
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 0	DATE:	02/09/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Applicants Cherry Cook and Anafe "Ana" Rivera		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to applicants Cherry Cook and Anafe "Ana" Rivera.

The facility fire clearance was granted on 09-20-2022 and reflects that the facility was approved for six residents in total, of which five (5) may be non-ambulatory, and one (1) may be bedridden.

During today’s visit, LPA, accompanied by the applicants, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 74 F. Water temperature at taps accessible to residents were also compliant: Kitchen was 109.2 F, Bathroom #1 was 106.9 F, Bathroom #2 was 106.7 F, and Bathroom #3 was 109.9 F.

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future resident use. Refrigerator temperature was 39 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential staff and resident records. The facility's swimming pool was fenced and behind a locked gate. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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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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: ANABELLAHOMECARE	FACILITY NUMBER: 374604614
	VISIT DATE: 02/09/2023

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[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. One (1) fire extinguisher and one (1) first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. The applicants passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Cook and Rivera advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicants, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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