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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604634
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:03:20 PM


Document Has Been Signed on 03/21/2024 04:03 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:POWAY GARDENS SENIOR LIVING - THE PINESFACILITY NUMBER:
374604634
ADMINISTRATOR:WILLIAMS, DONELLEFACILITY TYPE:
740
ADDRESS:12750 MONTE VISTA ROADTELEPHONE:
(858) 487-0736
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
03/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Donelle WilliamsTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted a Pre-licensing and Component III Visit to observe the physical plant for compliance per Title 22, Division 6 of the CA Code of Regulations and Health & Safety codes. LPA Correia was met by Executive Director (ED) Williams, identified herself, and was granted entry into the facility.

LPA Correia conducted a resident and staff facility records reviews and an interior and exterior facility tour of the physical plant. LPA Correia observed resident accommodations including required furnishings and linens. Resident bathrooms were equipped with non-skid flooring and grab bars and the water temperature read at approximately 118.9 F. in bathroom faucets, a secure location for administrative records was observed and complete. A first aid kit and manual were present. Toxins, cleaning supplies, and sharps are kept in a locked room or cabinet. Fire extinguishers are affixed with current tags. Facility staff conducted their last disaster drill on February 26, 2024; smoke and carbon monoxide detectors are present and operable; facility posting requirements were present in a common area and the facility administrators certification is current until June 22, 2024. Staff and resident records were complete. LPA observed 7 days of non-perishable and 2 days of perishable food. Facility employs activities specialists, dietician for residents. The facility meals are based on a dietician approved menu to ensure proper nutrition. LPA observed shaded outdoor areas, and a large common room for resident activities. Per ED Williams there are no firearms or weapons on the premises.

Fire clearance has been received and approved. The facility is ready for licensure once reviewed and approved by the program manager.

An exit interview was conducted with ED Williams, and a copy of this report and Licensee Appeal Rights (LIC 9058) were given for facility records.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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