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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881341
Report Date: 04/24/2024
Date Signed: 04/24/2024 12:41:20 PM

Document Has Been Signed on 04/24/2024 12:41 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KELLY'S SUNSET VILLAFACILITY NUMBER:
371881341
ADMINISTRATOR/
DIRECTOR:
WELKER, KELLY DFACILITY TYPE:
740
ADDRESS:1205 SUNSET HEIGHTS ROADTELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Garrett Welker, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Cristina Agoscruz, Caregiver. Administrator Garrett Welker arrived shortly.

A tour of the facility was conducted inside and out. LPA conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration.
The facility is a one story six (6) bedroom, three (3) bathroom home.

During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. There are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Licensee provided each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 115 degrees F. The facility had functioning carbon monoxide detectors, multiple smoke detectors, and one operable fire extinguisher. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and had a current Physician's Report, Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. LPA observed medications are stored and dispensed according to physician's orders

No deficiencies were observed during today's inspection. An exit interview was conducted and copy of this report was provided at the conclusion of the visit.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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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