374604818-8-12-2024-08-AS-LSIA-D83U9J-20240812152309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604818
Report Date: 08/09/2024
Date Signed: 08/12/2024 03:43:01 PM

Document Has Been Signed on 08/12/2024 03:43 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:	EPIC ASSISTANCE CARE HOME 4		FACILITY NUMBER:	374604818
ADMINISTRATOR:	MESDJIAN, LIZA		FACILITY TYPE:	740
ADDRESS:	1061 E BRADLEY AVE		TELEPHONE:	(818) 220-0282
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92021
CAPACITY:	15	CENSUS: 13	DATE:	08/09/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Lead Caregiver Priscilla Dizon		TIME COMPLETED:	03:30 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) Liliana Silveira conducted an announced Pre-Licensing continuation 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 Lead Caregiver Priscilla Dizon.

The facility fire clearance was granted on 06/25/24 and reflected that the facility was approved for 15 non-ambulatory residents aged 60 and above. The facility's fire clearance did not include endorsements for delayed-egress doors or secured perimeter. The submitted facility sketch was consistent with the current layout of the facility.

On 08/07/24 LPA and Assistant Administrator Silvana Huerta 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.

During today’s visit, LPA, accompanied by Priscilla Dizon, checked Hot water temperature at taps accessible to residents were also compliant: Bathroom #1 sink was 108 F, Bathroom #2 sink was 109.2 F and Bathroom #3 was 109.9 F. The facility’s ambient internal temperature was complaint at 105 degrees F.

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.

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. (CONTINUED ON LIC 809-C, NEXT PAGE)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: EPIC ASSISTANCE CARE HOME 4	FACILITY NUMBER: 374604818
	VISIT DATE: 08/09/2024

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
26
27
28
29
30
31
32

(CONTINUED FROM LIC 809)
No bodies of water were observed at the facility. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per Silvana Huerta, 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 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 reviewed the Component III Training with Silvana on 08/07/24. Silvana was advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with Priscilla, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2