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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604644
Report Date: 03/16/2023
Date Signed: 03/16/2023 07:50:17 PM

Document Has Been Signed on 03/16/2023 07:50 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:DIVINE LIGHT CARE HOMEFACILITY NUMBER:
374604644
ADMINISTRATOR:DIAZ, ROGELIOFACILITY TYPE:
740
ADDRESS:5105 BANCROFT DRIVETELEPHONE:
(619) 713-1053
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 6CENSUS: 6DATE:
03/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Applicants Rogelio "RJ" Diaz and Catherine DiazTIME COMPLETED:
07:55 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to applicants Rogelio "RJ" Diaz and Catherine Diaz.

The facility fire clearance was granted on 12-21-2022 and reflects that the facility was approved for six (6) residents in total, of whom all may be non-ambulatory, but none may be bedridden.

During today’s visit, LPA, accompanied by the applicants, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 72 F. Water temperature at taps accessible to residents were also compliant: Kitchen was 115.3 F, Bathroom #1 was 115 F, and Bathroom #2 was 111 F.

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for resident use. Refrigerator temperature was 40 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential client and staff records. The facility's pool was secured behind a locked fence. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility.


[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: DIVINE LIGHT CARE HOME
FACILITY NUMBER: 374604644
VISIT DATE: 03/16/2023
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[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Two (2) fire extinguishers and one (1) first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. The applicants passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. The Diaz's were advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicants, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC809 (FAS) - (06/04)
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