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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604617
Report Date: 12/14/2022
Date Signed: 12/14/2022 09:48:38 AM

Document Has Been Signed on 12/14/2022 09:48 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BENVOLENCE HOME CAREFACILITY NUMBER:
374604617
ADMINISTRATOR:VELASCO, JOFELFACILITY TYPE:
735
ADDRESS:922 MELROSE AVENUETELEPHONE:
(619) 227-7525
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 0DATE:
12/14/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jofel Velasco, AdministratorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Tammer De Los Santos conducted an announced Pre-Licensing inspection. LPA identified himself, discussed the purpose of the visit, and met with Administrator Jofel Velasco.

LPA conducted a tour of the facility, both inside and outside. There are no pools on site. The smoke and carbon monoxide alarms were present. Toilets intended for resident use were operating as intended, and bathing facilities were observed to be clean and kempt. The windows, blinds, and paint throughout the facility, were observed in good condition. Each room intended for resident use had the appropriate furniture, bedding, and appropriate lighting.
Administrator stated there are no firearms stored on the premises.

Hot water temperature was measured in the facility at 110 degrees F. The ambient temperature inside the facility was measured at 69 degrees F. The refrigerators and freezers were observed to be clean and operational, with an ample amount of food to meet client needs. Cleaning solutions were also properly secured.

The Component III portion of the application process was completed with the Administrator on today's date as well.

Pre-Licensing is complete, and this facility has no deficiencies. An exit interview was conducted with Administrator Jofel Velasco. The Applicant was provided with a copy of this report and Appeal/Licensee rights (LIC9058) via hardcopy at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tammer DeLosSantos
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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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