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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604795
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:04:43 AM

Document Has Been Signed on 07/16/2024 11:04 AM - 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:MISSION GUEST HOMEFACILITY NUMBER:
374604795
ADMINISTRATOR/
DIRECTOR:		CHONG, HENRIETTAFACILITY TYPE:
735
ADDRESS:424 E J STTELEPHONE:
(619) 240-3769
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
07/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Applicant's Representative, Henrietta "Candy" ChongTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted a 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, Henrietta "Candy" Chong.

The facility fire clearance was granted on 02-27-2024 and reflected that the facility was approved for six (6) clients in total, of which three (3) may be non-ambulatory and one (1) may be bedridden. Per the facility sketch, Bedroom #2 was approved for non-ambulatory, and Bedroom #1 was approved for bedridden or non-ambulatory. During today's visit: There were six (6) clients in care, of which two (2) were non-ambulatory and residing in the correct bedrooms. No current clients were 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 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. 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 75 degrees F. Hot water temperature at taps accessible to clients were also compliant: Kitchen sink was 119.7 F, Bathroom #1 sink was 116.2 F, and Bathroom #2 sink was 109 F.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for client use. All kitchen appliances were in working order. Kitchen Refrigerator temperature was 38 F, and Kitchen Freezer temperature was -1 F. Garage Refrigerator temperatures were 39 F and 39 F, respectively. Garage Freezer temperatures were 0 F and 0 F, respectively. [CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MISSION GUEST HOME
FACILITY NUMBER: 374604795
VISIT DATE: 07/16/2024
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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 sharp objects, 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 representative, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all operational. The facility's fire extinguisher was serviced within the last twelve (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. Chong 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.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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