374604690-7-14-2023-08-AS-DNGN-CTQUSB-20230714155003

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604690
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:50:11 PM

Document Has Been Signed on 07/14/2023 03:50 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:	CARROLL'S RESIDENTIAL CARE		FACILITY NUMBER:	374604690
ADMINISTRATOR:	MEYERS, BRYAN		FACILITY TYPE:	740
ADDRESS:	655 S MOLLISON AVE		TELEPHONE:	(619) 444-3181
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	144	CENSUS: 123	DATE:	07/14/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Applicant's Representatives, Administrator Bryan Meyers and Office Assistant Sarita Mendoza		TIME COMPLETED:	04:00 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 California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the Applicant's Representatives, Administrator Bryan Meyers and Office Assistant Sarita Mendoza.

The facility fire clearance was granted on 05/02/2023 and reflects that the facility was approved for 144 residents in total, of which 134 may be non-ambulatory, and 10 may be bedridden. 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 representatives, toured the interior and exterior of the facility and inspected each room. The facility was 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, sinks, and showers were in working order. The facility’s ambient internal temperature was complaint at 77 degrees F. Hot water temperature at taps accessible to residents were also compliant, where tested: Room #106 sink was 114.8 F, Room #115 sink was 113.4 F, Room #121 sink was 107.5, Room #144 sink was 112.6, and Room #166 sink was 110.5 F.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future resident use. Kitchen appliances were in working order. Refrigerator temperature was under 40 F, and freezer temperature was 0 F.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: CARROLL'S RESIDENTIAL CARE	FACILITY NUMBER: 374604690
	VISIT DATE: 07/14/2023

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[CONTINUED FROM LIC 809]

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 resident 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 resident. 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 all operational. Fire extinguishers were serviced within the last 12 months. A complete first aid kit was present. 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. Meyers was advised that the facility’s application is pending management final review and approval.

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

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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