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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804455
Report Date: 08/08/2022
Date Signed: 08/08/2022 04:45:28 PM

Document Has Been Signed on 08/08/2022 04:45 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:MESA BOARD AND CAREFACILITY NUMBER:
370804455
ADMINISTRATOR:MESA, CECILIAFACILITY TYPE:
740
ADDRESS:3865 DARWIN AVENUETELEPHONE:
(619) 934-9144
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY: 6CENSUS: 3DATE:
08/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Administrator, Cecilia MesaTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA), Marisela Garcia- Ceteno conducted a Case Management visit regarding an application for increase in nonambulatory capacity. LPA identified herself to and discussed the purpose of the visit with Administrator, Celilia Mesa.

Licensee applied for an increase in capacity from two (2) nonambulatory residents to four (4) nonambulatory residents. Fire Clearance was approved on June 23, 2022 for total capacity of six (6) of whom four (4) may be nonambulatory. As of today, there are three (3) residents in care. LPA toured the facility and a had a discussion with the Administrator regarding operation.

During the tour, LPA observed the physical plant and residents' accommodations including furnishings, linens and personal hygiene items; resident bathrooms are equipped with cleaning products and paper towels; toxic substances are stored in a locked cabinet in the garage and in the kitchen; medication storage and administration logs are located in a locked cabinet; sufficient space to conduct activities was present; facility posting requirements were present in a common area; the facility administrators certification was current; no pool or other body of water is present on the facility grounds; per the Administrator there are no guns, weapons or ammunition located on the property. Discussed with Administrator Cecilia Mesa, continuing operation requirements, record keeping and physical plant compliance.

No deficiencies were issued during this visit.

An exit interview was conducted with Administrator, Mesa to whom a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided at the conclusion of the visit.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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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