374604732-10-27-2023-08-AS-DNGN-CX23VX-20231027183553

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604732
Report Date: 10/27/2023
Date Signed: 10/27/2023 06:36:06 PM

Document Has Been Signed on 10/27/2023 06:36 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:	MENTAL HEALTH CENTER OF SAN DIEGO LLC		FACILITY NUMBER:	374604732
ADMINISTRATOR:	POTLA, PRAVESH		FACILITY TYPE:	772
ADDRESS:	2075 TORREY PINES ROAD		TELEPHONE:	(858) 285-9883
CITY:	LA JOLLA	STATE: CA	ZIP CODE:	92037
CAPACITY: 6		CENSUS: 0	DATE:	10/27/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	04:25 PM
MET WITH:	Applicants Representatives, Program Administrator Pravesh Potla and Program Director Tony Guerena		TIME COMPLETED:	06:45 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 the applicant’s representatives, Program Administrator Pravesh Potla and Program Director Tony Guerena.

The facility fire clearance was granted on 09/20/2023 and reflected that the facility was approved for six (6) clients in total, of which all must be ambulatory. The fire clearance specified that only the downstairs bedrooms may be used as client residences. 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 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 70 degrees F. Hot water temperature at taps accessible to clients were also compliant: Kitchen sink was 105.6 F, Bathroom #1 sink was 106.2 F, Bathroom #2 sink was 105.6 F, Bathroom #3 was 105.6, and Bathroom #4 was 105 F.

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. Kitchen Refrigerator temperature was 36 F, and Kitchen Freezer temperature was 0 F. Medication Refrigerator temperature was 33 F.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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: MENTAL HEALTH CENTER OF SAN DIEGO LLC	FACILITY NUMBER: 374604732
	VISIT DATE: 10/27/2023

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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’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. Potla and Guerena was 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: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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