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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604647
Report Date: 04/03/2024
Date Signed: 04/03/2024 06:53:13 PM


Document Has Been Signed on 04/03/2024 06:53 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:POWAY GARDENS SENIOR LIVING MAPLESFACILITY NUMBER:
374604647
ADMINISTRATOR:WILLIAMS, DONELLEFACILITY TYPE:
740
ADDRESS:12725 MONTE VISTA ROADTELEPHONE:
(658) 674-1255
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 3DATE:
04/03/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director Donelle WilliamsTIME COMPLETED:
03:45 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) Donelle Williams, identified herself, and was granted entry into the facility.

LPA Correia conducted a staff and resident records reviews and accompanied by ED Williams, a tour of the interior and exterior of the facility's physical plant. Residents supply their own furnishing unless requested, LPA observed required linens readily available upon a new admission. The resident bathrooms were equipped with non-skid flooring and grab bars, the water temperature read with in regulation in bathroom faucets used by residents in care. A secure location for administrative records was observed, a locked medication cart, and locked cabinets and rooms for toxins and sharp objects were also observed. A first aid kit and manual were present. LPA observed an adequate amount of Personal Protective Equipment (PPE) gear. Fire extinguishers are affixed with current tags. Smoke and carbon monoxide detectors were present and operable; facility posting requirements were present in a common area and the facility Administrator's certification is current until June 22, 2024. Staff and resident records were complete. LPA observed a supply of 2-day perishable and 7-day non-perishable food supply. Facility employs two full-time cooks, a dietary specialist, two activity specialists, on-site maintenance, and a laundry service. No bodies of water were observed on the property. Facility is equipped with a shaded outdoor area, 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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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