374601693-9-15-2023-08-AS-RHAL-CVPT49-20230915142334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601693
Report Date: 09/15/2023
Date Signed: 09/15/2023 02:23:38 PM

Document Has Been Signed on 09/15/2023 02:23 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:	PEPPERTREE GUEST HOME II		FACILITY NUMBER:	374601693
ADMINISTRATOR:	MARIO G. CAGAYAT		FACILITY TYPE:	740
ADDRESS:	8950 JOHNSON DRIVE		TELEPHONE:	(619) 460-8155
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY: 6		CENSUS: 5	DATE:	09/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Cherrlin Sanosa, Lead Caregiver		TIME COMPLETED:	02:25 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) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Cherrylin Sanosa, Lead Caregiver. LPA identified herself and disclosed the purpose of the visit with Cherrylin Sanosa, Lead Caregiver. Physical Environment: The facility was found to be clean, well-maintained, and free from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in good working condition. The facility's outdoor spaces were properly maintained and accessible for residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the needs of the residents. Staff members were observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications as per the licensing regulations. Staffing schedules were posted and adhered to, ensuring adequate coverage at all times. Continued on 809-C

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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: PEPPERTREE GUEST HOME II	FACILITY NUMBER: 374601693
	VISIT DATE: 09/15/2023

NARRATIVE

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Resident Care and Services: Residents' individual care plans were reviewed and found to be comprehensive and up-to-date. Medication administration was observed to be in accordance with the facility's policies and procedures. Residents' nutritional needs were met, and meals provided were nutritious and well-balanced.
Recreational activities and social engagement opportunities were available to residents on a regular basis.

Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergency situations and evacuation plans were readily available.

Overall, the facility was found to be in compliance with the licensing regulations. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) were provided to Cherrylin Sanosa. Her signature on this form confirms receipt of the documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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