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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604655
Report Date: 07/25/2023
Date Signed: 07/25/2023 03:39:04 PM

Document Has Been Signed on 07/25/2023 03:39 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:NELSON-HAVENFACILITY NUMBER:
374604655
ADMINISTRATOR:DOMINGO, ANGELITAFACILITY TYPE:
735
ADDRESS:1268 22ND STREETTELEPHONE:
(619) 233-0525
CITY:SAN DIEGOSTATE: CAZIP CODE:
92102
CAPACITY: 40CENSUS: 38DATE:
07/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Principal Lori Kennedy, Administrator Angelita Domingo and Manager Rhonda Gamble-HolmesTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Dang Nguyen 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 California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to applicant’s representatives, Principal Lori Kennedy, Administrator Angelita Domingo, and Manager Rhonda Gamble-Holmes.

The facility fire clearance was granted on 07/17/2023 and reflects that the facility was approved for forty (40) clients in total, of which all must be ambulatory. The facility's fire clearance did not include endorsements for delayed-egress doors or secured perimeter, and neither were present during today's visit. The submitted facility sketch was consistent with the current layout of the facility.



During today’s visit, LPA, accompanied by the applicant’s represenatives, toured the interior and exterior of the facility and inspected each room. The facility was clean and in good repair. Pathways were well lit and free of obstruction and slip hazards. Client bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was complaint at 76 F. Hot water temperature at taps accessible to clients were also compliant, where tested: First Floor Public Restroom by Room #105 was 117.1 F; First Floor Public Restroom by Room #109 was 109.8 F; First Floor Public Restroom by Room #111 was 107.2 F; Second Floor Public Restroom by Room #200 was 110.8 F; Second Floor Public Restroom by #204 was 109.2 F; and Second Floor Public Restroom by Room #210 was 116 F.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food client use. Kitchen appliances were in working order. In both the garage and kitchen, the refrigerator temperatures were 37 F, and the freezer temperatures were 0 F. [CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: NELSON-HAVEN
FACILITY NUMBER: 374604655
VISIT DATE: 07/25/2023
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[CONTINUED FROM LIC 809]

The facility has sufficient space and equipment to facilitate laundry, 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.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were operational. Fire extinguishers were serviced within the last 12 months. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection.

LPA also provided the Component III Training during today’s visit. Kennedy, Domingo, and Gamble-Holmes were advised that the facility’s application is pending management final review and approval.

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

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

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC809 (FAS) - (06/04)
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