374604651-3-10-2023-08-AS-DNGN-CPSS8R-20230310123933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604651
Report Date: 03/10/2023
Date Signed: 03/10/2023 12:39:44 PM

Document Has Been Signed on 03/10/2023 12:39 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:	HOPE INC IV		FACILITY NUMBER:	374604651
ADMINISTRATOR:	CAMACHO JR, ARTURO		FACILITY TYPE:	775
ADDRESS:	8125 BROADWAY		TELEPHONE:	(619) 933-3077
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY: 60		CENSUS: 0	DATE:	03/10/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Applicants Arthur "Arturo" Camacho Jr. and Luis Fernandez		TIME COMPLETED:	12:45 PM

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Licensing Program Analysts (LPA) Dang Nguyen and Alyssa Ramirez conducted an announced 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. LPAs were greeted by, identified themselves to, and explained the purpose of the visit to applicants Arthur "Arturo" Camacho Jr. and Luis Fernandez.

The facility fire clearance was granted on 02-03-2023 and reflects that the facility was approved for sixty (60) ambulatory client participants.

During today’s visit, LPAs, 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. Toilets and sinks were in working order. The facility’s ambient internal temperature was 70 F. Water temperatures at taps accessible to clients were compliant: Kitchen #1 was 110.5 F, Kitchen #2 was 108 F, Bathroom #1 was 107 F, Bathroom #2 was 108 F, Bathroom #3 was 107 F, Bathroom #4 was 109 F, and Bathroom #5 was 107 F.

The facility has enough personal care supplies and non-perishable food for future client use. Refrigerator temperature was 38 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate visitation, meetings, and client activities. The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. 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: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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: HOPE INC IV	FACILITY NUMBER: 374604651
	VISIT DATE: 03/10/2023

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[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Three (3) 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 applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit.

Camacho Jr. and Fernandez 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: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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