374604688-10-16-2023-08-AS-DNGN-CWNR7E-20231016124614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604688
Report Date: 10/16/2023
Date Signed: 10/16/2023 12:46:52 PM

Document Has Been Signed on 10/16/2023 12:46 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:	VILLA KALI MA		FACILITY NUMBER:	374604688
ADMINISTRATOR:	AMUNDSON, ASHLEY		FACILITY TYPE:	772
ADDRESS:	17676 VISTA RANCHO COURT		TELEPHONE:	(760) 683-5152
CITY:	RANCHO SANTA FE	STATE: CA	ZIP CODE:	92067
CAPACITY: 6		CENSUS: 0	DATE:	10/16/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Applicant's Representatives, Judith Kay White, Angela Nicole McMahon, and Ashley Amundson		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 the applicant’s representatives, Judith Kay White, Angela Nicole McMahon, and Ashley Amundson The facility fire clearance was granted on 09/27/2023 and reflected that the facility was approved for six (6) clients in total, of which all must 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 representative, 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. 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 75 degrees F. Hot water temperature at taps accessible to clients were also compliant: Main Kitchen sink was 113.4 F, Art Room Kitchen sink was 111.7 F, Clinical Wing Kitchen sink was 108.5 F, Smoothie Bar sink was 105.8 F, Utility sink was 113 F, Bathroom #1 sink was 117.8 F, Bathroom #2 sink was 112.6 F, Bathroom #3 sink was 111.2 F, Bathroom #4 sink was 113 F, Bathroom #5 sink was 111.2 F, Bathroom #6 sink was 108.6 F, Bathroom #7 sink was 108 F, Bathroom #8 sink was 106.8 F, and Bathroom #9 sink was 109.5 F. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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: VILLA KALI MA	FACILITY NUMBER: 374604688
	VISIT DATE: 10/16/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future client use. All kitchen appliances were in working order. Main Kitchen Refrigerator was 37 F, Beverage Refrigerator was 36 F, and Clinical Wing Refrigerator was 35 F. Main Kitchen Freezer was 0 F, and Clinical Wing Freezer was 0 F.

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.

The facility's swimming pool was secured behind a locking fence meeting regulations. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Per the applicant’s representatives, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. All fire extinguisher(s) 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. White, McMahon, and Amundson 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: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC809 (FAS) - (06/04)

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