371881341-3-29-2023-18-AS-JARA-CQDPEH-20230329111509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881341
Report Date: 03/29/2023
Date Signed: 03/29/2023 11:15:26 AM

Document Has Been Signed on 03/29/2023 11:15 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	KELLY'S SUNSET VILLA		FACILITY NUMBER:	371881341
ADMINISTRATOR:	WELKER, KELLY D		FACILITY TYPE:	740
ADDRESS:	1205 SUNSET HEIGHTS ROAD		TELEPHONE:	(619) 504-5049
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY: 6		CENSUS: 6	DATE:	03/29/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Administrator, Garrett Welker		TIME COMPLETED:	11:30 AM

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) Janira Arreola, made an announced visit to the facility on 3/28/2023 at 9:31 am in order to conduct a prelicensing inspection. LPA met with administrator Garrett Welker, who was informed of the purpose of the visit. The facility is seeking a new license for a change in ownership to K & K Senior Care Specialists Inc. The population served is for elderly ages 60 and up. LPA reviewed the pre licensing materials submitted by the applicant such as the facility sketch, emergency disaster plan, and infection control plan. LPA also reviewed the current administrator's certificate posted at the facility for Kelly Welker which was current with an expiration date of 7/24/2024. All these documents were found to be in compliance with department requirements. LPA conducted a walk through of the interior and exterior of the facility. The facility is a (1) story home with (7) bedrooms and (3) bathrooms, with attached garage. The fire clearance dated 01/04/2023 completed by City of Escondido fire department indicated the facility is licensed for 6 residents. The facility is approved for (6) ambulatory, (5) of which can be non-ambulatory and (1) of which can be bedridden. Bedroom #3 approved for bedridden was observed to have the (2) required exit door and seals on the door. The LPA was informed and observed that there are no fire arms, or bodies of water such as pool present at the facility. LPA observed the resident and staff bedrooms and bathrooms. Bathrooms had grab bars, hand hygiene supplies, and hand washing signs posted. The resident bedrooms were observed to have required furniture. LPA observed extra linens in the hallway closet as well as extra hygiene supplies in locked pantry and garage. LPA observed emergency water and PPE supplies in the facility garage. LPA observed the facility laundry equipment was function, and observed locked cleaning supplies. The facility has enough supplies to conduct regular cleaning of the facility. LPA observed locked sharp objects in the facility laundry room. LPA observed the closet were first aid kit, MARS, resident files, staff files, and resident medications. The facility kitchen had enough pots, pans, and cooking utensils. The food supply observed was in compliance with the 2-day perishable and 7-day non-perishable food requirements.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S SUNSET VILLA	FACILITY NUMBER: 371881341
	VISIT DATE: 03/29/2023

NARRATIVE

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LPA observed the hot water temperature in one of the resident restrooms to be 108F. LPA observed the facility dining area which could accommodate the licensed capacity. LPA observed activities being conducted with facility residents during the time of the visit. The facility poses a required carbon monoxide detector, and the smoke alarms were tested and found to be functional during the time of the visit. Required facility posting such as resident person rights, ombudsmen and complaint information, as well as emergency exits where found posted in the facility.

Component III orientation was conducted during the visit with the applicant over the phone Kelly Welker, and the with administrator Garrett Welker in person. An exit interview was conducted were this report was reviewed and provided to the administrator, Garrett Welker.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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