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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604614
Report Date: 02/15/2024
Date Signed: 02/20/2024 02:25:42 PM


Document Has Been Signed on 02/20/2024 02:25 PM - 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:
02/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Von RiveraTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct a case management - annual continuation visit to complete the annual inspection commenced on February 13, 2024. LPA was greeted and granted entry into the facility by Administrator Rivera, to whom LPA discussed the purpose of the visit.

During today’s visit, LPA, accompanied by Administrator Rivera, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature at taps accessible to residents in care were all with in regulation measuring at 110.F, and the facility temperature was 70 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored and labeled. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications and toxins are stored in locked areas inaccessible to residents in care

Faiclity has a pool on the premesis that has a 5-foot locked gate, no other bodies of water were present. Per Administrtor Rivera there was no ammunition kept at the facility. Smoke alarms, carbon monoxide detectors, and facility telephone were all operable. Fire extinguisher was serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. All required records for residents and staff were present and current.

No deficiencies were cited during today's annual inspection. An exit interview was conducted with Administrator/House Supervisor Rivera to whom a copy of this report and Licensee/Appeal Rights (LIC9058 03/22) will be provided. Signature below confirms receipt of the reports.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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