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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604837
Report Date: 02/12/2025
Date Signed: 02/12/2025 04:46:08 PM

Document Has Been Signed on 02/12/2025 04:46 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:PANCHITO'S PLACEFACILITY NUMBER:
374604837
ADMINISTRATOR/
DIRECTOR:		JACKSON, JEFFFACILITY TYPE:
735
ADDRESS:117 OXFORD ST.TELEPHONE:
(619) 349-2058
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 0DATE:
02/12/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Applicant's Representatives Jeff Jackson and Jose Gabriel SalomTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analysts (LPA) Dang Nguyen and Arian Golbakhsh 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. LPAs were greeted by, identified themselves to, and explained the purpose of the visit to the applicant’s representatives, Jeff Jackson and Jose Gabriel Salom.

The facility fire clearance was granted on 07/16/2024 and reflected that the facility was approved for four (4) clients in total, of whom all must be ambulatory. 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, LPAs, 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 68 degrees F. Hot water temperature at taps accessible to clients were also compliant: Kitchen sink was 109.4 F, Bathroom #1 sink was 108 F, and Bathroom #2 sink was 108.8 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 40 F, and Kitchen freezer temperature was 0 F. Garage Refrigerator temperature was 40 F, and Garage freezer temperature was 0 F.


[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PANCHITO'S PLACE
FACILITY NUMBER: 374604837
VISIT DATE: 02/12/2025
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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 or open-faced heaters accessible to clients. The facility's fireplace was screened, as required. 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 extinguishers were 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.

LPAs also provided the Component III Training during today’s visit. Jeff Jackson and Jose Gabriel Salom were 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: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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