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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604614
Report Date: 02/13/2024
Date Signed: 02/15/2024 08:33:50 AM


Document Has Been Signed on 02/15/2024 08:33 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:ANABELLA HOMECAREFACILITY NUMBER:
374604614
ADMINISTRATOR:VON RIVERA ALLANEFACILITY TYPE:
740
ADDRESS:14249 HIGH VALLEYTELEPHONE:
(406) 998-8022
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator Von RiveraTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct an annual licensing inspection. LPA identified herself to Caregiver Lawrence Vergara and was granted entry into the facility. Administrator Von Rivera was contacted and arrived at the facility to join the inspection. The facility is licensed to serve six (6) residents; of which all can be non-ambulatory and/or receiving Hospice Services, and 4 residents may be bedridden. During today's visit all 5 Residents were present.

LPA Correia conducted a resident records review, briefly spoke to resident in care, and, accompanied by Administrator Rivera, toured of facility. Per today's facility tour resident bedrooms and bathrooms were equipped with required furnishings, and precautionary. Smoke and carbon monoxide detectors, as well as a fire extinguisher were all present and operable, and up to date. An overall inspection of the facility began today however due to time constraints LPA was unable to complete the visit and will return at a later date to conduct the remaining portion of this inspection.



No deficiencies cited at today's visit. This report was discussed with Administrator Rivera. A copy of the report and License Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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