374604788-5-30-2024-08-AS-AROS-D5AQ49-20240515114959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604788
Report Date: 05/15/2024
Date Signed: 05/30/2024 03:59:13 PM

Document Has Been Signed on 05/30/2024 03:59 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ROCK OF AGES MANOR CARE		FACILITY NUMBER:	374604788
ADMINISTRATOR:	EVANGELISTA, MARYL		FACILITY TYPE:	740
ADDRESS:	7445 PACIFIC AVENUE		TELEPHONE:	(619) 844-4566
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY:	6	CENSUS: 0	DATE:	05/15/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator Maryl Evangelista		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Amy Rodgers 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 herself to, and explained the purpose of the visit to the applicant’s representative, Administrator Maryl Evangelista.

The facility fire clearance was granted on 2/7/2024 and reflected that the facility was approved for six (6) residents in total, of which all may be non-ambulatory and one (1) may be bedridden in room 2 only.Hospice Waiver granted for six (6)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 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 73 degrees F. Hot water temperature at taps accessible to residents were also compliant.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future resident use. All kitchen appliances were in working order. Refrigerator temperature was 38 F, and freezer temperature was 0 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.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROCK OF AGES MANOR CARE	FACILITY NUMBER: 374604788
	VISIT DATE: 05/15/2024

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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. The fire extinguisher was 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. Administrator Mayrl Evangwlista 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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

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