374604722-9-22-2023-08-AS-DNGN-CVX354-20230922175608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604722
Report Date: 09/22/2023
Date Signed: 09/22/2023 05:56:42 PM

Document Has Been Signed on 09/22/2023 05:56 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:	NOVELLUS CLAIREMONT LLC		FACILITY NUMBER:	374604722
ADMINISTRATOR:	LAIRD, CANDI		FACILITY TYPE:	740
ADDRESS:	5219 CLAIREMONT MESA BLVD.		TELEPHONE:	(858) 292-8044
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	214	CENSUS: 78	DATE:	09/22/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Applicant's Representative, Candi Laird		TIME COMPLETED:	06:15 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 representative, Executive Director Candi Laird.

The facility fire clearance was granted on 08/15/2023 and reflected that the facility was approved for 214 residents in total, of which 206 may be non-ambulatory and eight (8) may be bedridden. Only rooms #124 through #137 are approved for bedridden residents. The facility's fire clearance did not include delayed-egress door or secured perimeter endorsements, 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 resident rooms. 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 78 degrees F. Hot water temperature at taps accessible to residents were also compliant. On the first floor: Room #105 sink was 115.7 F, Room #120 sink was 115.7 F, Room #129 sink was 118.2 F, and Room #137 sink was 105.1 F. On the second floor: Room #207 sink was 117.1 F, Room #220 sink was 118.2 F, Room #232 sink was 120 F, and Room #258 sink was 115.7 F.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for resident use. Kitchen appliances were in working order. Kitchen Walk-In Refrigerator Temperature was 35 F, and Kitchen Walk-in Freezer temperature was -3 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: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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: NOVELLUS CLAIREMONT LLC	FACILITY NUMBER: 374604722
	VISIT DATE: 09/22/2023

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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 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 extinguisher 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. Laird 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: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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