374604692-11-22-2023-08-AS-DNGN-CXTSGQ-20231122125220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604692
Report Date: 11/22/2023
Date Signed: 11/22/2023 12:53:51 PM

Document Has Been Signed on 11/22/2023 12:53 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	WESTMONT OF CARMEL VALLEY		FACILITY NUMBER:	374604692
ADMINISTRATOR:	ROSSI, MARIA		FACILITY TYPE:	740
ADDRESS:	5720 OLD CARMEL ROAD		TELEPHONE:	(858) 465-7356
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92130
CAPACITY:	138	CENSUS: 17	DATE:	11/22/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Applicant's Respresentative, Regional Vice President of Operations Maria Rossi		TIME COMPLETED:	01:10 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 representative, Regional Vice President of Operations Maria Rossi. The facility fire clearance was granted on 10/10/2023 and reflected that the facility was approved for 138 residents in total, of which all may be non-ambulatory but none may be bedridden. The facility's fire clearance included approval for delayed-egress doors specific to the facility's memory care unit, and LPA found that such doors were compliant during today's visit. The facility's fire clearance did not include approval for secured perimeter, and that was not 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. 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 compliant at 71 degrees F. Hot water temperature at taps accessible to residents were also compliant: 1st Floor Men's Public Restroom sink was 114.1 F, 1st Floor Women's Restroom sink was 115.3 F, Memory Care Public Restroom sink was 107.1 F, Courtyard Men's Restroom sink was 116.6 F, Courtyard Women's Restroom sink was 114.1 F, Bistro/Cafe sink was 117.1 F, Activity Room sink was 116.4 F, and Lounge sink was 118.4 F. Room #102 sink was 109.2 F, Room #125 sink was 110.3 F, Room #164 sink was 109.9 F, Room #184 sink was 117.5 F, Room #202 sink was 107.2 F, Room #224 sink was 111 F, Room #246 sink was 118.4 F, and Room #260 sink was 118.8 F. [CONTINUED ON LIC 808-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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: WESTMONT OF CARMEL VALLEY	FACILITY NUMBER: 374604692
	VISIT DATE: 11/22/2023

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 resident use. All kitchen appliances were in working order. Refrigerator and freezer temperatures were also compliant: In the Main Kitchen, the Walk-In Refrigerator was 40 F, the Walk-In Freezer was 0 F, and the Ice Cream Freezer was -13 F. The Bistro Freezer was 0 F. The Medication Room Refrigerators were both 39 F.

The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of sharp objects, medication, and confidential resident and staff records.

The facility's swimming pool was secured behind a fence and locking gates meeting regulatory requirements. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant’s representative, 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 extinguishers were serviced within the last twelve 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. Rossi was advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicant’s representative, 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: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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