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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604620
Report Date: 12/12/2024
Date Signed: 12/12/2024 04:53:44 PM

Document Has Been Signed on 12/12/2024 04:53 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:LAKE CANYON HOME CAREFACILITY NUMBER:
374604620
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, OLIVER CUEVASFACILITY TYPE:
735
ADDRESS:9460 LAKE CANYON RDTELEPHONE:
6194866465
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 4CENSUS: 4DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Administrator Oliver Cuevas RodriguezTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced required annual inspection on December 12, 2024. LPA Correia identified herself and was granted entrance into the facility by Administrator Oliver Cuevas Rodriguez to whom was explained the purpose of the visit.


According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom all must be ambulatory. During today’s inspection there were three clients present in the facility and one staff member.

LPA Correia, accompanied by Administrator Cuevas Rodriguez, toured the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal and hot water temperature (71- and 115-degrees Fahrenheit, respectively) were with-in Licensing guidelines.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons accessible to clients. Medications were stored in locked areas.


[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LAKE CANYON HOME CARE
FACILITY NUMBER: 374604620
VISIT DATE: 12/12/2024
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[CONTINUED FROM LIC 809]

No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and the facility landline were all working. Fire extinguishers were in compliance. First aid kit and manual were readily accessible. Administrator’s certification was current as well as the facility’s liability insurance. LPA observed required postings at the facility.

LPA Correia reviewed multiple staff and client records/files that were observed to be complete and accurate. Client's P&I was accurate and complete.

An exit interview was conducted with Administrator Cuevas Rodriguez to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) will be provided at the conclusion of the visit.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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