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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850428
Report Date: 04/30/2024
Date Signed: 05/02/2024 03:36:33 PM

Document Has Been Signed on 05/02/2024 03:36 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PALS-LA JOLLA PLACE HOMEFACILITY NUMBER:
425850428
ADMINISTRATOR/
DIRECTOR:
HERNANDEZ, ARNOLDFACILITY TYPE:
735
ADDRESS:1477 LA JOLLA PLACETELEPHONE:
(562) 426-5444
CITY:CARPINTERIASTATE: CAZIP CODE:
93013
CAPACITY: 4CENSUS: 0DATE:
04/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Arnold Hernandez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an announced pre-licensing visit to the facility. Today’s visit was conducted with Arnold Hernandez, Administrator.
The facility is a one-story home which will be licensed as an Adult Residential Facility (ARF). Currently, there are no clients residing in the facility.
Interview Conducted:
The facility has a fire clearance for four (4) ambulatory clients. The facility consists of a: living room, a family room with the dining area, kitchen, four private bedrooms, one private staff room, two full bathrooms with hallway access, a two-car garage, and front and backyards.
Upon entrance of the residence, there is a walkway leading to a large front porch with entrance through the front door.
Entrance into the facility leads into the living room. The living room consists of a couch, sitting chair, coffee table, a fixed-screened fireplace, and a wall-mounted television.
The family room and dining area include a dining table, a couch, sitting chair, wall-mounted television, and a non-working stove heater.
The living room, family room, and dining area are furnished with adequate furnishings to sustain a capacity of four clients.
The kitchen consists of a refrigerator, dishwasher, microwave, sink, stove and oven, and a trash can with a flip lid. A washer and dryer are in a utility closet off the kitchen. Emergency food will be kept in the kitchen and laundry area.
There are two shared bathrooms off the hallway with access to all clients. The bathrooms have non-skid flooring and mats.
Clients’ records, personnel documents and records of confidentiality will be kept in a locked file cabinet located in the staff office. Sharps and medications will be kept in the locked staff office and will be inaccessible to clients in care.

Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALS-LA JOLLA PLACE HOME
FACILITY NUMBER: 425850428
VISIT DATE: 04/30/2024
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Clients may participate at will in various activities based on their individual interests and preferences.
The backyard consists of walkways, sitting areas, covered pergola, fruit trees, gardening area, and a secure fence around the outdoor area.
Recycling, green waste, and trash bins are standardized bins with flip lids. Each side of the residence has an unlocked entrance/exit gate.
There are ten (10) smoke detectors, three (3) fire extinguishers, and three illuminated exit signs in the facility.

The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings were checked. The facility was seen to be in good repair inside and outside.

The following items are needed prior to licensure:
Bedrooms 2, 3, 4 need nightstands and lamps.
The facility needs a mounted carbon monoxide detector.
The complaint poster, bill of rights, and Resident’s rights posters need to be mounted in the facility.

Exit interview conducted, copy of report issued at the time of the visit. A copy of this report will be forwarded to the Centralized Application Bureau (CAB) upon completion of the items noted above.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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